Flashcards in Chapter 42 Deck (28):
The registered nurse is assigning a practical nurse to care for a client who has leukemia. Which instruction does the registered nurse provide to the practical nurse when delegating this client’s care?
a. Evaluate the amount of protein the client eats.
b. Assess the client’s roommate for symptoms of infection.
c. Perform effective hand hygiene frequently.
d. Wear a mask when entering the room.
C: A major objective in caring for the client with leukemia is protection from infection. Frequent handwashing is of the utmost importance. If at all possible, the client should be in a private room. Masks are worn by anyone who has an upper respiratory tract infection. The client may be on a “minimal bacteria diet.” Protein is not a factor in this diet.
The nurse is teaching a client who has sickle cell disease and was admitted for splenomegaly and abdominal pain. Which instruction does the nurse include in the client’s discharge teaching?
a. “Avoid drinking large amounts of fluids.”
b. “Eat six small meals daily instead of large meals.”
c. “Engage in aerobic exercise 3 days a week.”
d. “Receive a yearly influenza vaccination.”
D: Abdominal pain and a palpable spleen could indicate blood trapping in the spleen. Over time, the spleen may become nonfunctional, which makes the client at risk for infection. An annual influenza vaccination helps prevent infection. A client with sickle cell disease should not become dehydrated or engage in strenuous physical activity because this could precipitate a crisis. Eating smaller meals has no impact on sickle cell disease or infection.
The nurse is planning discharge teaching for a client who has acute myelogenous leukemia (AML). Which instruction does the nurse include in this client’s discharge plan?
a. Avoid contact sports.
b. Refrain from intercourse.
c. Apply heat to any bruised areas.
d. Use aspirin for headaches.
A: Clients with AML have a low platelet count and are at risk for bleeding. Contact sports can cause bleeding and should be avoided by those with a low platelet count. Anal intercourse should be avoided, but it is not necessary to refrain from all types of intercourse. Ice should be placed on bruised areas instead of heat, and aspirin should not be used by those with a low platelet count.
The nurse is caring for a client who has autoimmune thrombocytopenic purpura. Which intervention does the nurse implement for this client?
a. Avoid intramuscular injections.
b. Administer prescribed anticoagulants.
c. Infuse intravenous normal saline.
d. Monitor for an increase in temperature.
A: With autoimmune thrombocytopenic purpura, the total number of circulating platelets is greatly reduced. As a result of the decreased platelet count, the client is at great risk for bleeding, and intramuscular injections should be avoided. Anticoagulants should not be given. A low platelet count is not treated with saline, and thrombocytopenia will not cause a change in body temperature.
The nurse is teaching a client who is being discharged after stem cell transplantation. Which instruction does the nurse include in this client’s discharge teaching?
a. Eat a diet high in fruits and vegetables.
b. Ask your provider to administer a rubella vaccination.
c. Wash your hands frequently.
d. Participate in physical therapy every day.
C: Protecting the client from infection at home is just as important as it was during hospitalization for a client who has had stem cell transplantation. Hand hygiene is the best protection against infection. Salads, raw fruits, and live vaccinations (such as rubella) are contraindicated in a client who has a risk for infection. Energy management is important; therefore activities such as physical therapy may need to be postponed.
The nurse prepares to administer a blood transfusion to a client. Which means of identification does the nurse use to ensure that the blood is administered to the correct client?
a. Ask the client whether his or her name is the one on the blood product tag.
b. Ask the client’s spouse if the client is supposed to have a transfusion.
c. Compare the name and ID number on the blood product tag with the name and ID number on the client’s ID band.
d. Compare the unit and room number of the client with the unit and room number listed on the blood product tag.
C: The safest way to determine whether the blood product is to be given to the correct client is to check the client’s hospital ID band and compare the information on it with that on the blood product tag. The room and unit numbers are never considered as means of positive identification. Asking the client who he or she is might result in an error if the client is confused. Similarly, a visitor cannot be assumed to know whether this is the client to have the blood transfusion. p.898
The nurse is providing health promotion education to a client who has a family history of leukemia. Which factor does the nurse teach this client to avoid?
a. Alcohol consumption
b. Exposure to ionizing radiation
c. High-cholesterol diet
d. Smoking cigarettes
B: Many genetic and environmental factors are involved in the development of leukemia. Exposure to radiation increases the risk for development of leukemia, particularly acute myelogenous leukemia (AML). Although alcohol consumption, high-cholesterol diet, and smoking are not healthy behaviors, they do not increase the risk for leukemia.
The nurse is assessing a client who has a factor VIII deficiency. Which clinical manifestation does the nurse expect to assess in this client?
a. Excessive bleeding from a cut
b. Chronic lower back pain
c. Nausea and vomiting
d. Temperature of 101° F
A: Factor VIII deficiency is also known as hemophilia A. With hemophilia, a client has a prolonged partial thromboplastin time (PTT) and is at risk for excessive bleeding from minor cuts. The other three distractors are not associated with a factor VIII deficiency. p.896
The nurse is planning care for a client who has leukemia. Which intervention does the nurse include in the plan of care to prevent fatigue?
a. Arrange for a family member to stay with the client.
b. Plan care for times when the client has the most energy.
c. Schedule for daily physicals and occupational therapy.
d. Plan all activities to occur in the morning to allow for afternoon naps.
B: With leukemia, energy management is needed to help conserve the client’s energy. Care should be scheduled when the client has the most energy. This client may not have the most energy in the morning. If the benefit of an activity such as physical or occupational therapy is less than its worsening of fatigue, it may be postponed. The nurse should limit the number of visitors and interruptions by visitors, as appropriate.
The nurse is teaching a client with vitamin B12 deficiency anemia to eat a diet high in this vitamin. Which meal selected by the client indicates that the client correctly understands the prescribed diet?
a. Baked chicken breast, mashed potatoes, glass of milk
b. Eggplant parmesan, cottage cheese, iced tea
c. Fried liver and onions, orange juice, spinach salad
d. Fettuccine alfredo, green salad, glass of red wine
C: Organ meats and leafy green vegetables have the highest content of vitamin B12. The other selections do not indicate understanding of the teaching on diet.
The nurse is teaching a client who has iron deficiency anemia. Which food choice indicates that the client correctly understands the teaching?
C: Treatment for iron deficiency anemia involves increasing oral intake of iron from food sources. Foods high in iron include red meat, organ meat, kidney beans, leafy green vegetables, and raisins.
The nurse assesses that a client has a smooth, beefy red tongue. Which intervention does the nurse implement for this client?
a. Administer prescribed oral iron supplements.
b. Monitor the daily white blood cell count.
c. Provide a diet high in green leafy vegetables.
d. Perform more frequent mouth care.
C: A smooth, beefy red tongue could signify glossitis, which is seen with vitamin B12 deficiency. Green leafy vegetables are high in vitamin B12. Iron supplements would be used with iron deficiency anemia. The red blood cell count is what is affected by vitamin B12 deficiency—not the white blood cell count. The beefy red tongue is caused by the vitamin deficiency, not by poor mouth care.
Which risk factor does the nurse assess for to determine a client’s cause of anemia?
a. Antacid therapy
b. Chronic alcoholism
c. Congestive heart failure
d. Type 2 diabetes
B: Chronic alcohol abuse is strongly associated with malnutrition of many dietary essentials, including iron, folic acid, and vitamin B12. Antacids, heart failure, and diabetes affect nutrition at varying levels, but anemia is most closely related to the malnutrition seen with chronic alcohol abuse.
The nurse is teaching a client who is being discharged to home after bone marrow transplantation. The client asks, “Why is it so important to protect myself from injury?” How does the nurse respond?
a. “Injuries put you at high risk for infection.”
b. “Platelet recovery is slow, which makes you at risk for bleeding.”
c. “Severe trauma could result in rejection of the transplant.”
d. “The medications you are taking will make you bruise easily.”
B: Platelets recover more slowly than other blood cells after bone marrow transplantation. Thus the client is still thrombocytopenic at home and remains at risk for excessive bleeding after any trauma or injury. Injured tissue makes a client at risk for infection, and trauma could result in injury to the transplant (but not rejection). However, these are not the best responses to give the client. A steroid regimen may make a client more at risk for bruising, but the most accurate response pertains to platelet recovery.
The nurse is preparing a client for surgery. The client states, “I am concerned I might be given blood products during surgery and this would be against my religious beliefs.” How does the nurse respond?
a. “We can use other means to replace blood loss besides blood products.”
b. “Your chance of needing a blood transfusion is small.”
c. “The operating team will do what is necessary to save your life.”
d. “You could have family members donate blood for you.”
A: The client’s rights and wishes should be respected while accurate information is provided for reassurance. Directed donations from family members neither ensure safe blood products nor may be sanctioned by the client’s religion.
The nurse is caring for a 20-year-old man who has Hodgkin’s lymphoma in the abdominal and pelvic regions. The client is scheduled for radiation therapy and states, “I want to have children someday, and this procedure will destroy my chances.” How does the nurse respond?
a. “Adoption is always an option.”
b. “Infertility is not seen with this type of radiation therapy.”
c. “Sperm production will be permanently disrupted.”
d. “You have the option to store sperm in a sperm bank.”
D: Permanent sterility can occur in male clients receiving radiation in the abdominal and pelvic regions. The client should be informed of this side effect and given the option to store sperm in a sperm bank before treatment. The other options do not appropriately address the client’s concerns.
The nurse is preparing a client with leukemia for a peripheral stem cell transfusion. Which information does the nurse provide the client?
a. “Nausea and vomiting are common after the transfusion.”
b. “The transfusion will take about 6 hours.”
c. “You may have numbness in your fingers and toes.”
d. “Your urine may be red for a short time.”
D: Red urine can occur as a result of red blood cell breakage within infused stem cells. The cells are transfused during the time frame of an ordinary blood transfusion, numbness and tingling may have been seen during pheresis (not transfusion), and nausea and vomiting may occur during administration of chemotherapy before the stem cell transfusion.
The nurse is caring for a client during a sickle cell crisis. Which intervention does the nurse implement for the client?
a. Administer acetaminophen (Tylenol) as needed.
b. Administer intravenous fluids to keep the vein open.
c. Keep the room temperature at 80° F.
d. Transfuse red blood cells (RBCs).
C: Keeping the room warm can be used as a complementary therapy to relieve the pain of a sickle cell crisis. Cold can act as a factor in causing a crisis. Analgesia is an important part of relieving pain. The analgesia routine should be followed on an around-the-clock basis and should consist of IV opioids for severe pain, followed by treatment with oral doses of opioids or NSAIDs. High-volume intravenous fluids should be administered to minimize pain during a sickle cell crisis.
The nurse is assessing a client with anemia. Which clinical manifestation does the nurse expect to see in this client?
a. Dyspnea with activity
d. Warm, flushed skin
A: Anemia is a reduction in the number of red blood cells (RBCs), the amount of hemoglobin, or the hematocrit level. Tissue oxygenation depends on RBCs. Typical symptoms of anemic clients include dyspnea, increased somnolence, tachycardia, and pallor. A client who is anemic tends to have lower blood pressure, increased heart rate, and skin that is pale and cool to touch.
The nurse is transfusing red blood cells to a client who has sickle cell disease. Which laboratory result indicates that the nurse should discontinue the transfusion?
a. Hematocrit level (Hct), 32%
b. Hemoglobin S, 88%
c. Serum iron level, 300 mcg/dL
d. Total white blood cell count, 12,000/mm3
C: Clients with sickle cell disease are anemic but are not iron deficient. Transfusions are prescribed cautiously to prevent iron overload with repeated transfusions. Iron overload damages the heart, liver, and endocrine organs. Monitor the client’s serum ferritin, serum iron (Fe), and total iron-binding capacity (TIBC) during transfusion therapy. The other laboratory values should not result in discontinuation of the transfusion by the nurse.
A client is newly diagnosed with sickle cell anemia. Which information does the nurse include in the client’s discharge instructions?
a. “Eat a diet high in iron.”
b. “Take hydroxyurea (Droxia) every morning.”
c. “Be aware of the early symptoms of crisis.”
d. “Do not use any oral contraceptives.”
C: Clients need to know the early symptoms of crisis so that treatment can be started early to prevent pain, complications, and permanent tissue damage. The iron level is not low in sickle cell anemia. Hydroxyurea is used in the hospital during a sickle cell crisis. The use of oral contraceptives is controversial because they may enhance clot formation, predisposing the client to crisis.
A client who has sickle cell anemia is admitted to the hospital. The client reports severe pain. Which action does the nurse take first?
a. Administer one unit of packed red blood cells.
b. Administer prescribed hydroxyurea (Droxia).
c. Begin intravenous fluids at 250 mL/hr.
d. Prepare for bone marrow transplantation.
C: All of these are treatments for sickle cell anemia. However, the client in severe pain is likely to be in sickle cell crisis. To prevent further sickling of the red blood cells, adequate hydration of at least 200 mL/hr is needed during a crisis. The other interventions should be implemented after the fluids are started.
The nurse is teaching a client who was recently diagnosed with thrombocytopenia. Which instruction does the nurse include in this client’s discharge teaching?
a. “Drink at least 3 liters of fluid each day.”
b. “Use a soft-bristled toothbrush.”
c. “Avoid blowing your nose.”
d. “Use only aspirin when having pain.”
B: Decreased platelet counts increase the risk for prolonged bleeding, even with slight injury. Fluid intake will not affect the platelet count. The client can blow his or her nose if necessary but should be instructed to do so gently. Aspirin should be avoided because it can cause an even greater risk of bleeding.
The nurse is teaching a client who has myelodysplastic syndrome. Which instruction does the nurse include in this client’s teaching?
a. “Rise slowly when getting out of bed.”
b. “Drink at least 3 liters of liquids per day.”
c. “Wear gloves and socks outdoors in cool weather.”
d. “Use a soft-bristled toothbrush.”
D: Myelodysplastic syndrome is a group of disorders that includes anemia, neutropenia, and thrombocytopenia. Because of low platelets, the client is at risk for bleeding. Using a soft-bristled toothbrush minimizes trauma to the gums and prevents bleeding. The other instructions are not appropriate for this syndrome.
The nurse observes that a client, whose blood type is AB-negative, is receiving a transfusion with type O-negative packed red blood cells. Which action does the nurse take first?
a. Report the problem to the blood bank.
b. Assess and record the client’s vital signs.
c. Stop the transfusion and keep the IV open.
d. Administer prescribed diphenhydramine (Benadryl).
B: Clients with an AB-negative blood type can receive O-negative blood because they do not have antibodies against this type of blood. The transfusion can proceed. The nurse monitors the client’s vital signs as if he or she were receiving type AB-negative packed red blood cells. The blood bank would not need to be called. Blood would not need to be stopped because the blood is compatible with the client’s blood type. Benadryl would be given only if the client had an allergic reaction.
The nurse is assessing a client with a history of heart failure who is receiving a unit of packed red blood cells. The client’s respiratory rate is 33 breaths/min and blood pressure is 140/90 mm Hg. Which action does the nurse take first?
a. Administer prescribed diphenhydramine (Benadryl).
b. Continue to monitor the client’s vital signs.
c. Stop the infusion of packed red blood cells.
d. Slow the infusion rate of the transfusion.
D: Circulatory overload can occur when a blood product is infused too quickly. Adults with a history of heart failure are at risk for this. Management of this complication can be achieved by infusing the blood products more slowly. The client is not having an allergic reaction to the blood; therefore the blood should not be stopped nor should diphenhydramine be administered.
A client who is receiving a unit of red blood cells begins to report chest and lower back pain. Which action does the nurse take first?
a. Administer morphine sulfate 1 mg IV.
b. Assess the level of the pain.
c. Stop the transfusion.
d. Reposition the client on the right side.
C: A hemolytic transfusion reaction is caused by blood type or Rh incompatibility. When blood containing antigens different from the client’s own antigens is infused, antigen-antibody complexes are formed in the client’s blood. Manifestations include low back pain and chest pain, and the transfusion should be discontinued immediately. The other actions are not the priority.