Question 6121)
The nurse is administering packed blood cells to a client. The nurse should first:
A. discontinue the IV catheter if a blood transfusion reaction occurs.
B. administer the PRBCs through a percutaneously inserted central catheter line with a 20 - gauge needle.
C. flush PRBCs with 5% dextrose and 0.45% normal saline solution.
D. stay with the client during the first 15 minutes of infusion.
Answer: D
Explanation: The most likely time for a blood transfusion reaction to occur is during the first 15 minutes or first 50 mL of the infusion.
Question 6122) The nurse is teaching a client and his family about the client's new diagnosis of hemochromatosis. Which information should the nurse include in the teaching plan?
A. Hemochromatosis is an autoimmune disorder that affects the HEF gene.
B. Individuals who are heterozygous of hemochromatosis rarely develop the disease.
C. Individuals who are homozygous for hemochromatosis are carriers of hemochromatosis.
D. Men are at greater risk for hemochromatosis.
Answer: B
Explanation: The nurse should teach the client and family that individuals who are heterozygous for hemochromatosis rarely develop the disease.
Question 6123)
A client who had received 25 mL of packed red blood cells how low back pain and pruritus. After stopping the infusion, the nurse should take what action next?
A. Administer prescribed antihistamine and an antipyretic.
B. Collect blood and urine samples and send to the lab.
C. Administer prescribed diuretics.
D. Administer prescribed vasopressors.
Answer: B
Explanation: ABO and Rh-incompatible blood causes an antigen-antibody reaction that produces hemolysis or agglutination of red blood cells.
Question 6124)
A client is to receive epoetin injections. What laboratory value should the nurse assess before giving the injection?
A. Hematocrit
B. Partial thromboplastin time
C. Hemoglobin concentration
D. Prothrombin time
Answer: A
Explanation: Epoetin is a recombinant DNA form of erythropoietin, which stimulates the production of red blood cells and therefore causes the hematocrit to rise.
Question 6125)
A client is afraid of receiving vitamin B12 injections because of potential toxic reactions. Which is the nurse's best response to relieve these fears?
A. Vitamin B12 will cause ringing in the ears before a toxic level is reached.
B. Vitamin B12 may cause a very mild rash initially.
C. Vitamin B12 cause mild nausea but nothing toxic.
D. Vitamin B12 is generally free to toxicity because it is water soluble.
Answer: D
Explanation: Vitamin B12 is a water soluble vitamin. When water soluble vitamins are taken in excess of the body needs, they are filtered through kidneys and excreted vit. B12 is considered be nontoxic.
Question 6126)
A client with macrocytic anemia has a burn on the foot and reports watching television while lying on a heating pad. Which action should be the nurse's first response?
A. Assess for potential abuse.
B. Check for diminished sensations.
C. Document the findings.
D. Clean and dress the area.
Answer: B
Explanation: Macrocytic anemias can result from deficiencies in vitamin B12 deficiency causes diminished sensations of peripheral nerve endings.
Question 6127)
Which is a late symptom of polycythaemia vera?
A. headache
B. dizziness
C. pruritus
D. Shortness of breath
Answer: C
Explanation: Pruritus is a late symptom that results from abnormal histamine metabolism.
Question 6128)
A 25 year old woman with a history of systemic lupus erythematosus was admitted with a severe viral respiratory tract infection and diffuse petechiae. Based on these data, it is most important that the nurse further evaluate the client's recent:
A. quality and quantity of food intake.
B. type and amount of fluid intake.
C. extent of weakness and fatigue.
D. length and amount of menstrual flow.
Answer: D
Explanation: A recent viral infection in a female client between the age of 20 and 30 with a history of systemic lupus erythematosus and an insidious onset of diffuse petechiae are hallmarks of idiopathic onset of diffuse petechiae purpura.
Question 6129)
When a client with thrombocytopenia has a severe headache, what does the nurse interpret that this may indicate?
A. stress of the disease
B. cerebral bleeding
C. migraine headache
D. sinus congestion
Answer: B
Explanation: When the platelet count is very low, red blood cells leak out of the blood vessels and into the tissue.
Question 6130)
A client's bone marrow report reveals normal stem cells and precursors of platelets (megakaryocytes) in the presence of decreased circulating platelets. The nurse recognizes a knowledge deficit when the client says:
A. I need to stop flossing and throw away my hard toothbrush.
B. I am glad that my report turned out normal.
C. Now I know why I have all these bruises.
D. I should not jump off that last step anymore.
Answer: B
Explanation: The client who states that the test results are normal has only heard that the bone marrow is functioning.
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