Question 6101)
A client who is weak, dyspneic and jaundiced has a bilirubin level greater than 2 mg/100 mL blood volume. With which problem are these clinical findings consistent?
A. Hemolytic anemia
B. Pernicious anemia
C. Decreased rate of red blood cell destruction
D. Low oxygen carrying capacity of erythrocytes
Answer: A
Explanation: An elevated plasma bilirubin level could indicate an increased rate of RBC destruction (bilirubin is a product of free hemoglobin metabolism): the individual may have a hemolytic anemia (e.g. thalassemia major [Cooley anemia], glucose-6-phosphate).
Question 6102)
Packed red blood cells have been prescribed for a female client with a hemoglobin level of 7.6 g/dL and a hematocrit level of 30%. The nurse takes the client's temperature before hanging the blood transfusion and records orally. Which action should the nurse takes:
A. Begin the transfusion as prescribed
B. Administer an antihistamine and begin the transfusion.
C. Delay hanging the blood and notify the health care provider.
D. Administer 2 tablets of acetaminophen and begin the transfusion.
Answer: C
Explanation: The client has a temperature higher than 100 degree F, the unit of blood should not be hung until the HCP is notified and has the opportunity to give further prescriptions. The HCP likely will prescribe that the blood be administered regardless of the temperature, or may instruct the nurse to administer prescribed acetaminophen and wait until the temperature has decreased before administration, but the decision is not within the nurse's scope of practice to make. The nurse needs an HCP's prescription to administer medications to the client.
Question 6103)
The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next?
A. Remove the intravenous line.
B. Run a solution of 5% dextrose in water.
C. Run normal saline at a keep-vein-open rate.
D. Obtain a culture of the tip of the catheter device removed from the client.
Answer: C
Explanation: If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further health care provider prescriptions. This maintains a patent IV access line and aids in maintaining the client's intravascular volume. The nurse would not remove the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should not be removed. Second, cultures are performed when infection not transfusion reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump.
Question 6104)
Client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous solution from the IV storage area to hang with the blood product at the client's bedside?
A. Lactated Ringer's
B. O.9% sodium chloride
C. 5% dextrose in 0.9% sodium chloride
D. 5% dextrose in 0.45% sodium chloride
Answer: B
Explanation: Sodium chloride 0.9% (normal saline) is a standard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells (RBCs). Lactated Ringer's is not the solution of choice with this procedure.
Question 6105)
The nurse is caring for a client who is receiving a blood transfusion and is complaining of a cough. The nurse checks the client's vital sings, which include temperature of 97.2 degree F, pulse of 108 beats per minute, blood pressure of 152/76 mm Hg, respiratory rate of 24 breaths per minute and an oxygen saturation level of 95% on room air. The client denies pain at this time. Based on this information, what initial action should the nurse take?
A. Collect a urine sample for analysis.
B. Place the client in an upright position.
C. Compare current data to baseline data.
D. Slow the rate of the blood transfusion.
Answer: C
Explanation: For the client receiving a blood transfusion, the nurse should monitor for potential complications of a transfusion. One of the complications is circulatory overload. Signs and symptoms of circulatory overload include cough, dyspnea, chest pain, wheezing on auscultation of the lungs, headache, hypertension,tachycardia and a bounding pulse, and distended neck veins. Based on the data in the question, the nurse should compare current data to baseline data. The nurse should also further assess the client for other signs and symptoms of circulatory overload. If the nurse still suspects this complication after comparing to baseline data, the nurse should then place the client in an upright position with the feet in a dependent position and slow the rate of the infusion. Collection of a urine sample should occur if the nurse suspects a transfusion reaction, such as a hemolytic reaction.
Question 6106)
A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias?
A. Infusion pump
B. Pulse oximeter
C. Cardiac monitor
D. Blood-warming device
Answer: D
Explanation: If several units of blood are to be administered rapidly a blood warmer should be used. Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. To prevent this, the nurse warms the blood with a blood-warming device. Pulse oximetry and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias. Electronic infusion devices are not helpful in this case because the infusion must be rapid and infusion devices generally are used to control the flow rate. In addition, not all infusion devices are made to handle blood or blood products.
Question 6107)
A client had a mastectomy followed by chemotherapy 6 months ago. She reports that she is now "unable to concentrate at her card game" and "it seems harder and harder to finish her errands because of exhaustion." Based on this information, the nurse should suggest that the client:
A. take frequent naps.
B. limit activities.
C. increase fluid intake.
D. avoid contact with others.
Answer: A
Explanation: The client is likely experiencing fatigue and should increase her periods of rest.
Question 6108)
The nurse has just admitted a 35 year old female client who has a serum vitamin B12 concentration of 800 pg/mL. Which laboratory findings should alert the nurse to focus the health history to obtain specific information about drug or alcohol use?
A. total bilirupbin, 0.3 mg/dL (5.1 umol/L)
B. serum creatinine 0.5 mg/dL (44.2 umol/L)
C. hemoglobin 16 g/dL (160 g/L)
D. folate 1.5 ng/mL (3.4 nmol/L)
Answer: D
Explanation: Normal range of folic acid is 1.8 to 9 ng/mL. (4.1 to 20.4 nmol/L) and normal range of vitamin B12 is 200 to 900 pg/mL (147.6 to 664 pmol/L).
Question 6109)
Which lab values should the nurse report to the healthcare provider when the client has anemia?
A. Schilling test result, elevated
B. intrinsic factor, absent
C. sedimentation rate , 16 mm/h
D. red blood cells (RBCs) within normal range
Answer: B
Explanation: The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall.
Question 6110)
The nurse is developing a teaching plan for the client with aplastic anemia. Which is most important to include the plan?
A. Eat animal protein and dark green leafy vegetables every day.
B. Avoid exposure to others with acute infections.
C. Practice yoga and medication to decrease stress and anxiety.
D. Get 8 hours of sleep at night and take naps during the day.
Answer: B
Explanation: Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia
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