Nokea
A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important?
- A. Correctly identifying client using two identifiers
- B. Double-checking client and blood type information
- C. Placing the client on strict bedrest until the pain subsides
- D. Reviewing the client's medical record for known allergies
Correct Answer: B
Rationale: This client has a hemolytic transfusion reaction, most commonly caused by blood type or Rh incompatibility. The nurse should double-check all identifying information for both the client and blood type to confirm the error. Documentation occurs after the client is stable. Bedrest may not be needed, and allergies to medications or environmental items are not related.
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A client with chronic anemia has had many blood transfusions. What medications does the nurse anticipate teaching the client about adding to the regimen? (Select all that apply.)
- A. Azacitidine (Vidaza)
- B. Darbepoetin alfa (Aranesp)
- C. Decitabine (Dacogen)
- D. Epoetin alfa (Epogen)
- E. Methylprednisolone (Solu-Medrol)
Correct Answer: B,D
Rationale: Darbepoetin alfa and epoetin alfa are red blood cell colony-stimulating factors that help increase red blood cell production. Azacitidine and decitabine are used for myelodysplastic syndromes, and methylprednisolone is a steroid not used for anemia.
A client has received a bone marrow transplant and is waiting for engraftment. What actions by the nurse are most appropriate? (Select all that apply.)
- A. Not allowing any visitors until engraftment
- B. Limiting the protein in the client's diet
- C. Having the client wear a mask
- D. Teaching visitors appropriate hand hygiene
- E. Telling visitors not to bring live flowers or plants
Correct Answer: C,D,E
Rationale: Clients awaiting engraftment are immunocompromised, requiring protective precautions like wearing a mask, strict hand hygiene for visitors, and avoiding fresh flowers or plants due to infection risks. Limiting protein is not beneficial, and completely barring visitors is overly restrictive.
A nurse caring for a client with sickle cell disease (SCD) reviews the clients laboratory work. Which finding should the nurse reports to the provider?
- A. Creatinine: 2.9 mg/dL
- B. Hemlacture: 30.9%
- C. Sodium: 147 mEq/L
- D. White blood cell count: 12,000/mm3
Correct Answer: A
Rationale: An elevated creatinine indicates kidney damage, which occurs in SCD. A hematocrit level of 30.9% is an expected finding, as is a slightly elevated white blood cell count. A sodium level of 147 mEq/L, although slightly high, is not concerning.
A client has thrombocytopenia. What client statement indicates the client understands self-management of this condition?
- A. I brush and use dental floss every day.
- B. I chew hard candy for my dry mouth.
- C. I usually put ice on bumps or bruises.
- D. Nonslip socks are best when I walk.
Correct Answer: C
Rationale: The client should be taught to apply ice to areas of minor trauma to reduce bleeding risk. Flossing is not recommended due to the risk of gum bleeding. Hard foods should be avoided to prevent injury, and while nonslip socks promote safety, they do not directly address thrombocytopenia management.
A client with multiple myeloma demonstrates worsening bone density on diagnostic scans. About what drug does the nurse plan to teach this client?
- A. Zoledronic acid (Zometa)
- B. Denosumab (Xgeva)
- C. Bortezomib (Velcade)
- D. Lenalidomide (Revlimid)
Correct Answer: A
Rationale: Zoledronic acid is a bisphosphonate commonly used to treat bone loss in multiple myeloma by inhibiting osteoclast activity, thus improving bone density. Denosumab is another option for bone health but is less commonly used in this context. Bortezomib and lenalidomide are used for treating multiple myeloma but primarily target the cancer cells, not specifically bone density.