The client is being admitted with folic acid–deficiency anemia. Which would be the most appropriate referral? 1. Alcoholic Anonymous. 2. Leukemia Society of America. 3. A hematologist. 4. A social worker.
1. Most clients diagnosed with folic acid anemia have developed the anemia from chronic alcohol abuse. Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. A referral to Alcoholics Anonymous would be appropriate.
The charge nurse is making assignments on a medical floor. Which client should be assigned to the most experienced nurse? 1. The client diagnosed with iron-deficiency anemia who is prescribed iron supplements. 2. The client diagnosed with pernicious anemia who is receiving vitamin B12 intramuscularly (IM). 3. The client diagnosed with aplastic anemia who has developed pancytopenia. 4. The client diagnosed with renal disease who has a deficiency of erythropoietin.
3. Pancytopenia is a situation that develops in clients diagnosed with aplastic anemia because the bone marrow is not able to produce cells of any kind. The client has anemia, thrombocytopenia, and leukopenia. This client could develop an infection or hemorrhage, go into congestive heart failure, or have a number of other complications develop. This client needs the most experienced nurse.
The client diagnosed with anemia begins to complain of dyspnea when ambulating in the hall. Which intervention should the nurse implement first? 1. Apply oxygen via nasal cannula. 2. Get a wheelchair for the client. 3. Assess the client’s lung fields. 4. Assist the client when ambulating in the hall.
2. The client is experiencing dyspnea on exertion, which is common for clients with anemia. The client needs a wheelchair to limit the exertion.
The nurse is transcribing the HCP’s order for an iron supplement on the MAR. At which time should the nurse schedule the daily dose? 1. 0900. 2. 1000. 3. 1200. 4. 1630.
2. This is approximately two (2) hours after breakfast and is the correct dosing time for iron to achieve the best effects. Iron preparations should be administered one (1) hour before a meal or two (2) hours after a meal. Iron can cause gastrointestinal upset, but if administered with a meal, absorption can be diminished by as much as 50%.
The nurse is discharging a client diagnosed with anemia. Which discharge instruction should the nurse teach? 1. Take the prescribed iron until it is completely gone. 2. Monitor pulse and blood pressure at a local pharmacy weekly. 3. Have a complete blood count checked at the HCP’s office. 4. Perform isometric exercise three (3) times a week.
3. The client should have a complete blood count regularly to determine the status of the anemia.
The nurse writes a client problem of “activity intolerance” for a client diagnosed with anemia. Which intervention should the nurse implement? 1. Pace activities according to tolerance. 2. Provide supplements high in iron and vitamins. 3. Administer packed red blood cells. 4. Monitor vital signs every four (4) hours.
1. The client’s problem is activity intolerance, and pacing activities directly affect the diagnosis.
The charge nurse in the intensive care unit is making client assignments. Which client should the charge nurse assign to the graduate nurse who has just finished the three (3)-month orientation? 1. The client with an abdominal peritoneal resection who has a colostomy. 2. The client diagnosed with pneumonia who has acute respiratory distress syndrome. 3. The client with a head injury developing disseminated intravascular coagulation. 4. The client admitted with a gunshot wound who has an H&H of 7 and 22.
1. This is a major surgery but has a predictable course with no complications identified in the stem, and a colostomy is expected with this type of surgery. The graduate nurse could be assigned this client.
Which client would be most at risk for developing disseminated intravascular coagulation (DIC)? 1. A 35-year-old pregnant client with placenta previa. 2. A 42-year-old client with a pulmonary embolus. 3. A 60-year-old client receiving hemodialysis three (3) days a week. 4. A 78-year-old client diagnosed with septicemia.
4. DIC is a clinical syndrome that develops as a complication of a wide variety of other disorders, with sepsis being the most common cause of DIC.
The client admitted with full-thickness burns may be developing DIC. Which signs/ symptoms would support the diagnosis of DIC? 1. Oozing blood from the IV catheter site. 2. Sudden onset of chest pain and frothy sputum. 3. Foul smelling, concentrated urine. 4. A reddened, inflamed central line catheter site.
1. The signs/symptoms of DIC result from clotting and bleeding, ranging from oozing blood to bleeding from every body orifice and into the tissues.
Which laboratory result would the nurse expect in the client diagnosed with DIC? 1. A decreased prothrombin time (PT). 2. A low fibrinogen level. 3. An increased platelet count. 4. An increased white blood cell count.
2. The fibrinogen level helps predict bleeding in DIC. As it becomes lower, the risk of bleeding increases.
Which collaborative treatment would the nurse anticipate for the client diagnosed with DIC? 1. Administer oral anticoagulants. 2. Prepare for plasmapheresis. 3. Administer frozen plasma. 4. Calculate the intake and output.
3. Fresh frozen plasma and platelet concentrates are administered to restore clotting factors and platelets.
The unlicensed nursing assistant asks the primary nurse, “How does someone get hemophilia A?” Which statement would be the primary nurse’s best response? 1. “It is an inherited x-linked recessive disorder.” 2. “There is a deficiency of the clotting factor VIII.” 3. “The person is born with hemophilia A.” 4. “The mother carries the gene and gives it to the son.”
4. This is a true statement and explains exactly how someone gets hemophilia A: the mother passes it to the son.
Which sign/symptom should the nurse expect to assess in the client diagnosed with hemophilia A? 1. Epistaxis. 2. Petechiae. 3. Subcutaneous emphysema. 4. Intermittent claudication.
1. Nosebleeds along with hemarthrosis, cutaneous hematoma formation, bleeding gums, hematemesis, occult blood, and hematuria are all signs/symptoms of hemophilia.
Which situation might cause the nurse to think that the client has von Willebrand’s disease? 1. The client has had unexplained episodes of hematemesis. 2. The client has microscopic blood in the urine. 3. The client has prolonged bleeding following surgery. 4. The female client developed abruptio placentae.
3. von Willebrand’s disease is a type of hemophilia. The most common hereditary bleeding disorder, it is caused by a deficiency in von Willebrand’s (vW) factor and is often diagnosed after prolonged bleeding following surgery or dental extraction.
The client with hemophilia A is experiencing hemarthrosis. Which intervention should the nurse recommend to the client? 1. Alternate aspirin and acetaminophen to help with the pain. 2. Apply cold packs for 24–48 hours to the affected area. 3. Perform active range of motion exercise on the extremity. 4. Put the affected extremity in the dependent position.
2. Hemarthrosis is bleeding into the joint. Applying ice to the area can cause vasoconstriction, which can help decrease bleeding.
Which sign would the nurse expect to assess in the client diagnosed with idiopathic thrombocytopenia purpura (ITP)? 1. Petechiae on the anterior chest, arms, and neck. 2. Capillary refill of less than three (3) seconds. 3. An enlarged spleen. 4. Pulse oximeter reading of 95%.
1. ITP is due to bleeding from small vessels and mucous membranes. Petechiae, tiny purple or red spots that appear on the skin as a result of minute hemorrhages within the dermal or submucosal layers, and purpura, hemorrhaging into the tissue beneath the skin and mucous membranes, are the first signs of ITP.
The nurse is caring for the following clients. Which client should the nurse assess first? 1. The client whose partial thromboplastin time (PTT) is 38 seconds. 2. The client’s whose hemoglobin is 14 gm/dL and hematocrit is 45%. 3. The client’s whose platelet count is 75,000 per milliliter of blood. 4. The client’s whose red blood cell count is 48 106 mm.
3. A platelet count of less than 100,000 per milliliter of blood indicates thrombocytopenia.
Which nursing interventions should the nurse implement when caring for a client diagnosed with hemophilia A? Select all that apply. 1. Instruct the client to use a razor blade to shave. 2. Avoid administering enemas to the client. 3. Encourage participation in noncontact sports. 4. Teach the client how to apply direct pressure if bleeding occurs. 5. Explain the importance of not flossing gums.
2. Enemas, rectal thermometers, and intramuscular injections can pose a risk of tissue and vascular trauma that can precipitate bleeding. 3. Even minor trauma can lead to serious bleeding episodes; safer activities such as swimming or golf should be recommended. 4. Direct pressure occludes bleeding vessels.
The client has a hematocrit of 22.3% and a hemoglobin of 7.7 mg/dL. The HCP has ordered two (2) units of packed red blood cells to be transfused. Which interventions should the nurse implement? Select all that apply. 1. Obtain a signed consent. 2. Initiate a 22-gauge IV. 3. Assess the client’s lungs. 4. Check for allergies. 5. Hang a keep-open IV of D5W.
1. The client must give permission to receive blood or blood products because of the nature of potential complications. 3. Because infusing IV fluids can cause a fluid volume overload, the nurse must assess for congestive heart failure. Assessing the lungs includes auscultating for crackles and other signs of left-sided heart failure. Assessing the client for jugular vein distention, peripheral edema, and liver engorgement indicates right-sided failure. 4. Checking for allergies is important prior to administering any medication. Some medications are administered prior to blood administration.
The client is admitted to the emergency department after a motor-vehicle accident. The nurse notes profuse bleeding from a right-sided abdominal injury. Which intervention should the nurse implement first? 1. Type and cross-match for red blood cells immediately (STAT). 2. Initiate an IV with a #18-gauge needle and hang NS. 3. Have the client sign a consent for an exploratory laparotomy. 4. Notify the significant other of the client’s admission.
2. The first action in a situation in which the nurse suspects the client has a fluid volume loss is to replace the volume as quickly as possible.
The nurse is working in a blood bank facility procuring units of blood from donors. Which client would not be a candidate to donate blood? 1. The client who had wisdom teeth removed a week ago. 2. The nursing student who received a measles immunization 2 months ago. 3. The mother with a six (6)-week-old newborn. 4. The client who developed an allergy to aspirin in childhood.
3. The client cannot donate blood for 6 months after a pregnancy because of the nutritional demands on the mother.
The client with O+blood is in need of an emergency transfusion but the lab does not have any O+blood available. Which potential unit of blood could be given to the client? 1. The O- unit. 2. The A+ unit. 3. The B+ unit. 4. Any Rh unit.
1. O- (O negative) blood is considered the universal donor because it does not contain the antigens A, B, or Rh. (AB is considered the universal recipient because a person with this blood type has all the antigens on the blood).
The client is scheduled to have a total hip replacement in two (2) months and has chosen to prepare for autologous transfusions. Which medication would the nurse to prepare the client? 1. Prednisone, a glucocorticoid. 2. Zithromax, an antibiotic. 3. Ativan, a tranquilizer. 4. Epogen, a biologic response modifier.
4. Epogen or Procrit are forms of erythropoietin, substance in the body that stimulates the bone marrow to produce red blood cells. A client may be prescribed iron preparations to prevent depletion of iron stores and erythropoietin to increase RBC production. A unit of blood can be withdrawn once a week beginning at 6 weeks prior to surgery. No phlebotomy will be done within 72 hours of surgery
The client undergoing knee replacement surgery has a “cell-saver” apparatus attached to the knee when he arrives in the post-anesthesia care unit (PACU). Which intervention should the nurse implement to care for this drainage system? 1. Infuse the drainage into the client when a prescribed amount fills the chamber. 2. Attach an hourly drainage collection bag to the unit and discard the drainage. 3. Replace the unit with a continuous passive motion unit and start it on low. 4. Have another nurse verify the unit number prior to reinfusing the blood.
1. A cell saver is a device to catch the blood lost during orthopedic surgeries to reinfuse into the client, rather than giving the client donor blood products. The cells are washed with saline and reinfused through a filter into the client. The salvaged cells cannot be stored and must be used within four (4) hours or discarded because of bacterial growth.
Which statement is the scientific rationale for infusing a unit of blood in less than four (4) hours? 1. The blood will coagulate if left out of the refrigerator for longer than four (4) hours. 2. The blood has the potential for bacterial growth if allowed to infuse longer. 3. The blood components begin to break down after four (4) hours. 4. The blood will not be affected; this is a laboratory procedure.
2. Blood is a medium for bacterial growth, and any bacteria contaminating the unit will begin to grow if left outside of a controlled refrigerated temperature for longer than four (4) hours, placing the client at risk for septicemia.
The HCP orders two (2) units of blood to be administered over eight (8) hours each for a client diagnosed with heart failure. Which intervention(s) should the nurse take? 1. Call the HCP to question the order because blood must infuse within four (4) hours. 2. Retrieve the blood from the laboratory and run each unit at an eight (8)-hour rate. 3. Notify the lab to split each unit into half units and infuse each half for four (4) hours. 4. Infuse each unit for four (4) hours, the maximum rate for a unit of blood.
3. The correct procedure for administering a unit of blood over eight (8) hours is to have the unit split into halves. Each half unit is treated as a new unit and checked accordingly. This slower administration allows the compromised client, such as one with heart failure, to assimilate the extra fluid volume.
The client receiving a unit of PRBCs begins to chill and develops hives. Which action should be the nurse’s first response? 1. Notify the laboratory and health-care provider. 2. Administer the histamine-1 blocker, Benadryl, IV. 3. Assess the client for further complications. 4. Stop the transfusion and change the tubing at the hub.
4. The priority in this situation is to prevent a further reaction if possible. Stopping the transfusion and changing the fluid out at the hub will prevent any more of the transfusion from entering the client’s bloodstream.
The nurse and unlicensed nursing assistant are caring for clients on an oncology floor. Which nursing task would be delegated to the unlicensed nursing assistant? 1. Assess the urine output on a client who has had a blood transfusion reaction. 2. Take the first 15 minutes of vital signs on a client receiving a unit of PRBCs. 3. Auscultate the lung sounds of a client prior to a transfusion. 4. Assist a client who received ten (10) units of platelets in brushing teeth.
4. The unlicensed nursing assistant can assist a client to brush the teeth. Instructions about using soft-bristle toothbrushes and the need to report to the nurse any pink or bleeding should be given prior to delegating the procedure.
The nurse is caring for clients on a medical floor. After the shift report, which client should be assessed first? 1. The client who is two-thirds of the way through a blood transfusion and has had no complaints of dyspnea or hives. 2. The client diagnosed with leukemia who has a hematocrit of 18% and petechiae covering the body. 3. The client with peptic ulcer disease who called over the intercom to say that he is vomiting blood. 4. The client diagnosed with Crohn’s disease who is complaining of perineal discomfort.
3. This client has a potential for hemorrhage and is reporting blood in the vomitus. This client should be assessed first.
The client received two (2) units of packed red blood cells of 250 mL with 63 mL of preservative each during the shift. There was 240 mL of saline remaining in the 500- mL bag when the nurse discarded the blood tubing. How many milliliters of fluid should be documented on the intake and output record?____________________
886 mL of fluid has infused. 250 mL + 63 mL =313 mL per unit. 313 + 313 = 626 ml. 500 mL of saline – 240 mL remaining 260 mL infused 626 mL +260 mL = 886 mL of fluid infused.