Clinical Reasoning Cases in Nursing
7th EditionJulie S Snyder, Mariann M Harding
2,512 solutions
The Human Body in Health and Disease
7th EditionGary A. Thibodeau, Kevin T. Patton
1,505 solutions
The Human Body in Health and Disease
7th EditionGary A. Thibodeau, Kevin T. Patton
1,505 solutions
Medical Language for Modern Health Care
4th EditionDavid M Allan, Rachel Basco
2,732 solutions
Recommended textbook solutions
The Human Body in Health and Disease
7th EditionGary A. Thibodeau, Kevin T. Patton
1,505 solutions
Pharmacology and the Nursing Process
7th EditionJulie S Snyder, Linda Lilley, Shelly Collins
388 solutions
Clinical Reasoning Cases in Nursing
7th EditionJulie S Snyder, Mariann M Harding
2,512 solutions
Medical Terminology for Health Professions
8th EditionAnn Ehrlich, Carol L Schroeder, Katrina A Schroeder, Laura Ehrlich
1,792 solutions
-
Flashcards
-
Learn
-
Test
-
Match
-
Flashcards
-
Learn
-
Test
-
Match
Terms in this set [52]
A patient with an acute peptic ulcer and major blood loss requires an immediate transfusion with packed red blood cells. Which task is appropriate for [RN] to delegate to [UAP]?
Obtain the vital signs before the transfusion is initiated.
The RN may delegate tasks such as taking vital signs to UAP.
nurse's duty
Assessments [e.g., monitoring for signs of a blood transfusion reaction [shortness of breath and back pain]]
are within the scope of practice of the RN and may not be delegated to UAP.
The RN must also assume responsibility for ensuring the correct IV fluid is used with blood products.
A licensed nurse must complete verification of the patient's identity and the blood product data.
The blood bank notifies the nurse that the two units of blood ordered for a patient is ready for pick up. Which action should the nurse take to prevent an adverse effect during this procedure?
Infuse the blood slowly for the first 15 minutes of the transfusion.
Because a transfusion reaction is more likely to occur at the beginning of a transfusion, the nurse should initially infuse the blood at a rate no faster than 2 mL/min and remain with the patient for the first 15 minutes after hanging 1 unit of blood.
Only 1 unit of blood can be picked up at a time, it must be infused within 4 hours, and it cannot be hung with dextrose.
The nurse is caring for a patient with microcytic, hypochromic anemia. What teaching should the nurse provide that would be beneficial to the patient?
Take the iron with orange juice one hour before meals.
The iron prescribed should be taken with orange juice one hour before meals as it is best absorbed in an acid environment.
microcytic, hypochromic anemia
may be caused by iron, vitamin B6, or copper deficiency;
thalassemia; or lead poisoning.
Megaloblastic anemias
occur with cobalamin [vitamin B12] and folic acid deficiencies.
Vitamin B12
may help red blood cell [RBC] maturation if the patient has the intrinsic factor in the stomach.
Green leafy vegetables
provide folic acid for RBC maturation
Antiseizure drugs
may contribute to aplastic anemia or folic acid deficiency, but the patient should not stop taking the medications.
The health care provider will prescribe changes in medications.
The nurse knows that hemolytic anemia can be caused by which extrinsic factors?
Macroangiopathic or microangiopathic factors
Macroangiopathic or microangiopathic extrinsic factors lead to acquired hemolytic anemias.
Trauma or splenic sequestration crisis
can lead to anemia from acute blood loss.
Abnormal hemoglobin or enzyme deficiency
are intrinsic factors that lead to hereditary hemolytic anemias.
Chronic diseases or medications and chemicals
can decrease the number of red blood cell [RBC] precursors which reduce RBC production.
A patient with cancer is having chemotherapy treatments and has now developed neutropenia. What care should the nurse expect to provide and teach the patient about?
Strict hand washing
Daily skin care and oral hygiene
Strict hand washing and daily skin and oral hygiene must be done with neutropenia, because the patient is predisposed to
infection from the normal body flora;
other people; and uncooked meats, seafood, and eggs; unwashed fruits and vegetables; and fresh flowers or plants.
Private room with a high-efficiency particulate air [HEPA] filter
The private room with HEPA filtration reduces the aerosolized pathogens in the patient's room.
Blood cultures and antibiotic treatment
are used when the patient has a temperature of 100.4°F or more, but temperature is not monitored every hour.
The patient is admitted with hypercalcemia; polyuria; and pain in the pelvis, spine, and ribs with movement. Which hematologic problem is likely to display these manifestations in the patient?
Multiple myeloma
Multiple myeloma.
typically manifests with skeletal pain and osteoporosis that may cause hypercalcemia, which can result in polyuria, confusion, or cardiac problems.
Serum hyperviscosity syndrome
can cause renal, cerebral, or pulmonary damage.
Thrombocytopenia, megaloblastic anemia, and myelodysplastic syndrome are not characterized by these manifestations.
The nurse is caring for a patient with a diagnosis of disseminated intravascular coagulation [DIC]. What is the first priority of care?
Treat the causative problem.
Treating the underlying cause of DIC will interrupt the abnormal response of the clotting cascade and reverse the DIC.
Blood product administration
occurs based on the specific component deficiencies and is reserved for patients with life-threatening hemorrhage.
Heparin
will be administered if the manifestations of thrombosis are present and the benefit of reducing clotting outweighs the risk of further bleeding.
The nurse is caring for a patient with a diagnosis of immune thrombocytopenic purpura [ITP]. What is a priority nursing action in the care of this patient?
Administration of oral or IV corticosteroids
Common treatment modalities for ITP
include corticosteroid therapy to suppress the phagocytic response of splenic macrophages.
Blood transfusions, administration of clotting factors, and reverse isolation are not interventions that are indicated in the care of patients with ITP.
Standard precautions are used with all patients.
Before beginning a transfusion of packed red blood cells [PRBCs], which action by the nurse would be of highest priority to avoid an error during this procedure?
Check the identifying information on the unit of blood against the patient's ID bracelet.
The patient's identifying information [name, date of birth, medical record number] on the ID bracelet should exactly match the information on the blood bank tag that has been placed on the unit of blood.
If any information does not match, the transfusions should not be hung because of possible error and risk to the patient.
The transfusion hung
is hung on blood transfusion tubing, not a secondary line,
and cannot be hung with lactated Ringer's solution because it will cause RBC hemolysis.
transfusion monitoring
Usually, the patient will need continuous monitoring for 15 minutes after the transfusion is started, as this is the time most transfusion reactions occur.
Then the patient should be monitored every 30 to 60 minutes during the administration.
Which patient is most likely to experience anemia related to an increased destruction of red blood cells?
A 23-yr-old African American man who has a diagnosis of sickle cell disease
A result of a sickling episode in sickle cell anemia involves increased hemolysis of the sickled cells.
Thalassemias and folic acid deficiencies
cause a decrease in erythropoiesis, whereas the anemia related to menstruation is a direct result of blood loss.
The nurse instructs an African American man who has sickle cell disease about symptom management and prevention of sickle cell crisis. The nurse determines further teaching is necessary if the patient makes which statement?
"When my vision is blurred, I will close my eyes and rest for an hour."
Blurred vision should be reported immediately and may indicate a detached retina or retinopathy.
Hypoxia [at high altitudes] and infection are common causes of a sickle cell crisis.
Severe pain may occur during a sickle cell crisis, and narcotic analgesics are indicated for pain management.
The nurse is caring for a patient with polycythemia vera. What is an important action for the nurse to initiate?
Assist with or perform phlebotomy at the bedside.
Primary polycythemia vera often requires phlebotomy in order to reduce blood volume.
The increased risk of thrombus formation that accompanies the disease requires regular exercises and ambulation.
Deep breathing and coughing exercises do not directly address the etiology or common sequelae of polycythemia, and neurologic manifestations are not typical.
The patient with leukemia has acute disseminated intravascular coagulation [DIC] and is bleeding. What diagnostic findings should the nurse expect to find?
Elevated D-dimers
The D-dimer is a specific marker for the degree of fibrinolysis and is elevated with DIC.
FDP is elevated as the breakdown products from fibrinogen and fibrin are formed.
Fibrinogen and platelets are reduced.
PT, PTT, aPTT, and thrombin time are all prolonged.
A patient with leukemia is admitted for severe hypovolemia after prolonged diarrhea has a platelet count of 43,000/µL. It is most important for the nurse to take which action?
Check stools for presence of frank or occult blood
A platelet count below 150,000/µL indicates thrombocytopenia.
Prolonged bleeding from trauma or injury does not usually occur until the platelet counts are below 50,000/µL.
Bleeding precautions [e.g., check all secretions for frank and occult blood] are indicated for patients with thrombocytopenia.
Injections [including IVs] should be avoided; however, when needed for critical fluids and medications, IV access should be provided through the smallest bore devices that are feasible.
Monitoring temperature would be indicated in a patient with leukopenia.
Enoxaparin, an anticoagulant
is contraindicated in patients with thrombocytopenia
A patient has been diagnosed with acute myelogenous leukemia [AML]. What should the nurse educate the patient that care will focus on?
Attaining remission
Attaining remission is the initial goal of care for leukemia. The methods to do this are decided based on age and cytogenetic analysis.
The treatments include leukapheresis or hydroxyurea to reduce the white blood cell count and risk of leukemia-cell-induced thrombosis.
A combination of chemotherapy agents will be used for aggressive treatment to destroy leukemic cells in tissues, peripheral blood, and bone marrow and minimize drug toxicity. In nonsymptomatic patients with chronic lymphocytic leukemia, waiting may be done to attain remission, but not with AML.
A patient with a diagnosis of hemophilia had a fall down an escalator earlier in the day and is now experiencing bleeding in the left knee joint. What should be the emergency nurse's immediate action?
Resting the patient's knee to prevent hemarthroses
In patients with hemophilia, joint bleeding requires resting of the joint to prevent deformities from hemarthrosis.
Clotting factors, not platelets or corticosteroids, are administered. T
hrombus formation is not a central concern in a patient with hemophilia.
A patient who has sickle cell disease has developed cellulitis above the left ankle. What is the nurse's priority for this patient?
Maintain oxygenation.
Maintaining oxygenation is a priority as sickling episodes are frequently triggered by low oxygen tension in the blood which is commonly caused by an infection.
Antibiotics to treat cellulitis, pain control, and fluids to reduce blood viscosity will also be used, but oxygenation is the priority.
The nurse receives a physician's order to transfuse fresh frozen plasma to a patient with acute blood loss. Which procedure is most appropriate for infusing this blood product?
Infuse the fresh frozen plasma as rapidly as the patient will tolerate.
The fresh frozen plasma
should be administered as rapidly as possible and should be used within 24 hours of thawing to avoid a decrease in factors V and VIII.
Fresh frozen plasma is infused using any straight-line infusion set.
Any existing IV should be interrupted while the fresh frozen plasma is infused, unless a second IV line has been started for the transfusion.
The nurse notes a physician's order written at 10:00 AM for two units of packed red blood cells to be administered to a patient who is anemic as a result of chronic blood loss. If the transfusion is picked up at 11:30 AM, the nurse should plan to hang the unit no later than what time?
12:00 noon
The nurse must hang the unit of packed red blood cells within 30 minutes of signing them out from the blood bank.
The nurse is caring for a patient who is to receive a transfusion of two units of packed red blood cells. After obtaining the first unit from the blood bank, the nurse would ask which health team member in the nurses' station to assist in checking the unit before administration?
Another registered nurse
Before hanging a transfusion, the registered nurse must check the unit with another RN or with a licensed practical [vocational] nurse, depending on agency policy.
The unit secretary, physician's assistant, or unlicensed assistive personnel should not be asked.
When preparing to administer an ordered blood transfusion, which IV solution does the nurse use when priming the blood tubing?
0.9% sodium chloride
The blood set should be primed before the transfusion with 0.9% sodium chloride, also known as normal saline. I
t is also used to flush the blood tubing after the infusion is complete to ensure the patient receives blood that is left in the tubing when the bag is empty.
Dextrose and lactated Ringer's solutions
cannot be used with blood because they will cause RBC hemolysis.
When caring for a patient with metastatic cancer, the nurse notes a hemoglobin level of 8.7 g/dL and hematocrit of 26%. What associated clinical manifestations does the nurse anticipate observing?
Fatigue
The patient with a low hemoglobin and hematocrit is anemic and would be most likely to experience fatigue.
Fatigue develops because of the lowered oxygen-carrying capacity that leads to reduced tissue oxygenation to carry out cellular functions.
Thirst, headache, and abdominal pain are not related to anemia.
A patient has anemia related to inadequate intake of essential nutrients. Which intervention would be appropriate for the nurse to include in the plan of care for this patient?
Encourage foods high in protein, iron, vitamin C, and folate.
Increased intake of protein, iron, folate, and vitamin C provides nutrients needed for maximum iron absorption and hemoglobin production.
The other interventions do not address the patient's identified problem of inadequate intake of essential nutrients.
Selection of foods
are soft, bland, and nonacidic is appropriate if the patient has oral mucosal irritation.
Scheduled rest
is an appropriate intervention if the patient has fatigue related to anemia.
medications that may inhibit iron absorption
[e.g., antacids, tetracycline, soft drinks, tea, coffee, calcium, phosphorus, and magnesium salts]
is important but does not address the patient's problem of inadequate intake of essential nutrients.
Before starting a transfusion of packed red blood cells for an older anemic patient, the nurse would arrange for a peer to monitor his or her other assigned patients for how many minutes when the nurse begins the transfusion?
15
As part of standard procedure, the nurse remains with the patient for the first 15 minutes after starting a blood transfusion.
Patients who are likely to have a transfusion reaction will more often exhibit signs within the first 15 minutes that the blood is infusing.
Monitoring during the transfusion
will be every 30 to 60 minutes.
The nurse is assigned to care for several patients on a medical unit. Which patient should the nurse check on first?
A 40-yr-old patient with a temperature of 100.8oF [38.2oC] and a neutrophil count of 256/μL
A low-grade fever greater than 100.4°F [38°C] in a patient with a neutrophil count below 500/μL is a medical emergency and may indicate an infection.
An infection in a neutropenic patient
could lead to septic shock and possible death if not treated immediately.
A patient will receive a hematopoietic stem cell transplant [HSCT]. What is the nurse's priority after the patient receives combination chemotherapy before the transplant?
Prevent patient infection.
After combination chemotherapy for HSCT, the patient's bone marrow is destroyed in preparation to receive the bone marrow graft.
Thus the patient is immunosuppressed and is at risk for a life-threatening infection.
The priority is preventing infection.
Bleeding is not usually a problem.
Giving the pneumococcal vaccine at this time should not be done; it should have been done previously.
Providing companionship is not the primary role of the nurse, although the patient will need support during the time of isolation.
Sets with similar termsLewis: MED-SURG: Chapter 31: Hematologic Problems…
43 terms
karmagenie
Lewis: MED-SURG: Chapter 31: Hematologic Problems…
44 terms
ktchappell0178
Lewis: MED-SURG: Chapter 31: Hematologic Problems
44 terms
Kate_Neverman
N230 Ch31 NCLEX practice
23 terms
rnformcf111
Sets found in the same folderN230 Ch31 NCLEX practice
23 terms
ksparks01
Chapter 46 AKI CKD
21 terms
wmtonn
Chapter 39 Review Questions
35 terms
rose-aquiPLUS
Chapter 41 Review Questions
50 terms
rose-aquiPLUS
Other sets by this creatorResearch
24 terms
rose-aquiPLUS
Research
24 terms
rose-aquiPLUS
Research
11 terms
rose-aquiPLUS
ch 5
12 terms
rose-aquiPLUS
Recommended textbook solutionsThe Language of Composition: Reading, Writing, Rhetoric
2nd EditionLawrence Scanlon, Renee H. Shea, Robin Dissin Aufses
661 solutions
Technical Writing for Success
3rd EditionDarlene Smith-Worthington, Sue Jefferson
468 solutions
Technical Writing for Success
3rd EditionDarlene Smith-Worthington, Sue Jefferson
468 solutions
Literature and Composition: Reading, Writing,Thinking
1st EditionCarol Jago, Lawrence Scanlon, Renee H. Shea, Robin Dissin Aufses
1,697 solutions
Other Quizlet setsTheology - Quiz 1 Study Guide
16 terms
hforeman98
CJUS 205 Midterm
99 terms
c00296504
Florida Driver License Test 2021
83 terms
Jalyn_Randall6
BIOL 2312 Quiz 2
27 terms
Loughlin_Douglas6
Related questionsQUESTION
would it ever be possible for a bacterium that did not pick up pGLO plasmid to live on the LB plates containing ampicillin?
7 answers
QUESTION
What document lists the safety hazards associated with a resin used in composite structures?
15 answers
QUESTION
What are the three sins against unity?
15 answers
QUESTION
Why did hezekiah destroy Moses' bronze serpent
15 answers