NCA II Test 4 - Immunity
The nurse on the pediatric unit is caring for a 10-year-old boy with a diagnosis of hemophilia. The nurse knows that a priority nursing diagnosis for a patient with hemophilia is what? A)Hypothermia B)Diarrhea C)Ineffective coping DImbalanced nutrition: Less than body requirements
Ans: C Feedback: Most patients with hemophilia are diagnosed as children. They often require assistance in coping with the condition because it is chronic, places restrictions on their lives, and is an inherited disorder that can be passed to future generations. Children with hemophilia are not at risk of hypothermia, diarrhea, or imbalanced nutrition.
A patient with sickle cell anemia has a a) Normal hematocrit b) High hematocrit c) Normal blood smear d) Low hematocrit
Low hematocrit Explanation: The patient with sickle cell anemia has a low hematocrit and sickled cells on the smear. The patient with sickle cell trait usually has a normal hemoglobin level, a normal hematocrit, and a normal blood smear. Page 911
Which is the following is the most obvious sign of anemia? a) Jaundice b) Flow murmurs c) Tachycardia d) Pallor
Pallor Explanation: On physical examination, pallor is the most common and obvious sign of anemia. Other findings may include tachycardia and flow murmurs. Patients with hemolytic anemia may exhibit jaundice and spelnomegaly. (less) Page 902
Which of the following terms refers to an abnormal decrease in white blood cells, red blood cells, and platelets? a) Thrombocytopenia b) Pancytopenia c) Anemia d) Leukopenia
Pancytopenia Explanation: Pancytopenia may be congenital or acquired. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of WBCs in circulation. Thrombocytopenia refers to a lower-than-normal platelet count. Page 907
Which of the following terms refers to an abnormal decrease in white blood cells, red blood cells, and platelets? a) Anemia b) Pancytopenia c) Thrombocytopenia d) Leukopenia
Pancytopenia may be congenital or acquired. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of WBCs in circulation. Thrombocytopenia refers to a lower-than-normal platelet count. Page 907
For a patient diagnosed with pernicious anemia, the nurse emphasizes the importance of lifelong administration of which of the following? a) Folic acid b) Vitamin A c) Vitamin C d) Vitamin B12
Vitamin B12 Explanation: For a patient with pernicious anemia, the nurse emphasizes the importance of lifelong administration of vitamin B12. He or she teaches the patient or a family member of the proper method to administer vitamin B12 injections. Administration of vitamin A, folic acid, or vitamin C is not recommended for this condition. Page 904
The nurse begins a routine blood transfusion of packed red blood cells (PRBCs) at 1100. To ensure client safety, the unit of blood should be completely transfused by what time? a) 1500 b) 1115 c) 1600 d) 1530
a) 1500 Administration time for PRBCs should not exceed 4 hours because of the increased risk of bacterial proliferation. For the first 15 minutes, the transfusion should be run slowly- no faster than 5 mL/min.
A client receiving a blood transfusion complains of shortness of breath, appears anxious, and has a pulse of 125 beats/minute. What is the best action for the nurse to take after stopping the transfusion and awaiting further instruction from the healthcare provider? a) Ensure there is an oxygen delivery device at the bedside. b) Place the client in a recumbent position with legs elevated. c) Remove the intravenous line. d) Administer prescribed PRN anti-anxiety agent.
a) Ensure there is an oxygen delivery device at the bedside. The client is exhibiting signs of circulatory overload. After stopping the transfusion and notifying the healthcare provider, the nurse should place the client in a more upright position with the legs dependent to decrease workload on the heart. The IV line is kept patent in case emergency medications are needed. Oxygen and morphine may be needed to treat severe dyspnea. Administering an anti-anxiety agent is not a priority action over ensuring oxygen is available.
Choice Multiple question - Select all answer choices that apply. The thalassemias are a group of hereditary anemias characterized by which of the following? Select all that apply. a) Anemia b) Hemolysis c) Thrombocytopenia d) Hypochromia e) Extreme microcytosis
• Hypochromia • Extreme microcytosis • Hemolysis • Anemia Explanation: The thalassemias are a group of hereditary anemias characterized by hypochromia, extreme microcytosis, destruction of blood elements (hemolysis), and variable degrees of anemia. Thrombocytopenia is not associated with thalassemias. Page 915
A client is prescribed 325 mg/day of oral ferrous sulfate. The nurse includes in client teaching, "Take your iron pill a) 1 hour before breakfast" b) with dairy products" c) and decrease fruits and juices in your diet" d) along with a decreased amount of dietary fiber"
1 hour before breakfast" Explanation: Instructions the nurse will provide for the client taking oral ferrous sulfate is to administer the medication on an empty stomach. Instructions also include that there is decreased absorption of iron with food, particularly dairy products. The client is to increase vitamin C intake (fruits, juices, tomatoes, broccoli), which will enhance iron absorption. The client is to also increase foods high in fiber to decrease risk of constipation. Page 905
Which of the following is the most common hematologic condition affecting elderly patients a) Leukopenia b) Thrombocytopenia c) Bandemia d) Anemia
Anemia Explanation: Anemia is the most common hematologic condition affecting elderly patients: with each successive decade of life, the incidence of anemia increases. Thrombocytopenia is a low platelet count. Leukopenia is a low leukocyte count. Bandemia is an increased number of band cells. Page 901
The charge nurse should intervene when observing a new nurse perform which action after a client has suffered a possible hemolytic blood transfusion reaction? a) Disposing of the blood container and tubing in biohazard waste. b) Notifying the blood bank of the reaction. c) Documenting the reaction in the client's medical record. d) Informing the client to leave a urine sample after the client's next void.
a) Disposing of the blood container and tubing in biohazard waste. The blood container and tubing should be returned to the blood bank for repeat typing and culture, and the blood bank should be notified of the reaction. A urine sample is collected as soon as possible to detect hemoglobin in the urine. Documenting the client's reaction in the medical record is an appropriate action.
A patient is brought to the ER complaining of fatigue, large amounts of bruising on the extremities, and abdominal pain localized in the left upper quadrant. A health history reveals the patient has been treated three times in the past 2 months for a sore throat. Lab tests indicate severe anemia, significant neutropenia, and thrombocytopenia. Based on the symptoms, with what could the patient be diagnosed? a) Sickle cell anemia b) Iron deficiency anemia c) Hemolytic anemia d) Aplastic anemia
Aplastic anemia Explanation: Aplastic anemia can be congenital or acquired, but most cases are idiopathic. It can be triggered by infection. The manifestations of aplastic anemia are symptoms of anemia, purpura (bruising), retinal hemorrhages, significant neutropenia, and thrombocytopenia. Other lymphadenopathies and splenomegaly sometimes occur.
A patient was admitted to the hospital with the following lab values: hemoglobin 5 g/dL, abnormally shaped erythrocytes, leukocyte count 2000/mm3 with hypersegmented neutrophils and a platelet count of 48,000/mm3. The platelets appear abnormally large. A bone marrow biopsy was competed and revealed hyperplasia. Based on this information, the nurse determines that patient most likely has which of the following diagnoses? a) Sickle cell anemia b) Folic acid deficiency c) Thalassemia d) Hemolytic anemia
Folic acid deficiency Explanation: Anemia caused by a deficiency of folic acid cause bone marrow and peripheral blood changes. The erythrocytes that are produced are abnormally large and are called megaloblastic red cells. Other cells derived from the myeloid stem cell are also abnormal. A bone marrow analysis reveals hyperplasia (abnormal increase in the number of cells). Pancytopenia (a decrease in all myeloid stem cell-derived cells) can develop. In advanced stages of disease, the hemoglobin value may be as low as 4 to 5 g/dL, the leukocyte count 2,000 to 3,000/mm3, and the platelet count less than 50,000/mm3. Cells that are released into the circulation are often abnormally shaped. The neutrophils are hypersegmented. The platelets may be abnormally large. The erythrocytes are abnormally shaped. Page 907
After teaching the patient about taking daily oral iron preparations for a moderate iron deficiency anemia, which statement made by the patient indicates to the nurse that additional instruction is still needed? a) "I will take the iron with orange juice about an hour before eating." b) "I will call the doctor if my stools turn black." c) "I will increase my fluid and fiber intake while I am taking the iron tablets." d) "I will occasionally take a stool softener if I feel constipated."
"I will call the doctor if my stools turn black." Correct Explanation: Iron replacement therapy may change the color of stool. Iron is best absorbed on an empty stomach, the patient is instructed to take the supplement an hour before meals. Many patients have difficulty tolerating iron supplements because of gastrointestinal (GI) side effects (primarily constipation). Limit GI side effects by the addition of a stool softener or increase of dietary fiber and fluids. Taking iron-rich foods with a source of vitamin C (e.g., orange juice) enhances the absorption of iron. Page 905
A young male client is diagnosed with a mild form of hemophilia. He is experiencing bleeding in the joints with pain. In preparing the client for discharge, the nurse educates the client to a) Take warm baths to lessen pain. b) Wear a medical identification bracelet. c) Take ibuprofen (Motrin) for joint pain. d) Undergo genetic testing and counseling.
Wear a medical identification bracelet. Explanation: Clients with hemophilia should wear a medical identification bracelet about having this disease. Ibuprofen interferes with platelet aggregation and may increase the client's bleeding. A warm bath may lessen pain but increase bleeding. Genetic testing and counseling are not necessary for male clients, because females are the carriers of the genetic material for hemophilia. Page 927