Nokea
A 1-year-old is admitted to the hospital with sickle cell anemia in crisis. Upon admission, which therapy will assume priority?
- A. Fluid administration
- B. Exchange transfusion
- C. Anticoagulant
- D. IM administration of iron and folic acid
Correct Answer: A
Rationale: Fluid administration is the priority in sickle cell crisis to prevent dehydration and reduce blood viscosity, which can worsen sickling.
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The nurse is discharging a client diagnosed with anemia. Which discharge instruction should the nurse teach?
- A. Take the prescribed iron until it is completely gone.
- B. Monitor pulse and blood pressure at a local pharmacy weekly.
- C. Have a complete blood count checked at the HCP’s office.
- D. Perform isometric exercise three (3) times a week.
Correct Answer: C
Rationale: Multiple Choice CBC checks (C) monitor anemia recovery. Taking iron indefinitely (A) depends on cause, BP/pulse checks (B) are nonspecific, and isometric exercise (D) may strain low oxygen capacity.
The client who received 50 mL from a unit of whole blood has low back pain. In response to this client’s symptom, which action should be taken by the nurse first?
- A. Reposition the client.
- B. Assess the pain further.
- C. Administer an analgesic.
- D. Stop the blood transfusion.
Correct Answer: D
Rationale: A. Repositioning focuses on treating the client’s back pain and not on the blood transfusion, which could be the cause of the back pain. B. Further assessment should occur after stopping the blood transfusion. C. The client may need an analgesic for pain control, but this should occur after stopping the blood transfusion. D. Low back pain is a symptom of a potentially life-threatening acute hemolytic reaction. The pain is caused from agglutination of RBCs in the kidneys and renal vasoconstriction. Hemolytic reactions occur most often within the first 50 mL of the infusion.
Fifteen minutes after the nurse has initiated a transfusion of packed red blood cells, the client becomes restless and complains of itching on the trunk and arms. Which intervention should the nurse implement first?
- A. Collect urine for analysis.
- B. Notify the laboratory of the reaction.
- C. Administer diphenhydramine, an antihistamine.
- D. Stop the transfusion at the hub.
Correct Answer: D
Rationale: Restlessness/itching suggest a transfusion reaction; stopping at the hub (D) prevents further reaction. Urine collection (A), notification (B), and Benadryl (C) follow.
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 administer to prepare the client?
- A. Prednisone, a glucocorticoid.
- B. Zithromax, an antibiotic.
- C. Ativan, a tranquilizer.
- D. Epogen, a biologic response modifier.
Correct Answer: D
Rationale: Epogen (D) stimulates RBC production for autologous donation. Prednisone (A), Zithromax (B), and Ativan (C) are unrelated.
The client’s laboratory values are RBCs 5.5 (x106/mm3), WBCs 8.9 (x103/mm3), and platelets 189 (x103/mm3). Which intervention should the nurse implement?
- A. Prepare to administer packed red blood cells.
- B. Continue to monitor the client.
- C. Request an order for Neupogen, a biologic response modifier.
- D. Institute bleeding precautions.
Correct Answer: B
Rationale: Labs are normal (RBC 5.5, WBC 8.9, platelets 189); continue monitoring (B). Transfusions (A), Neupogen (C), and bleeding precautions (D) are unnecessary.