Nokea
A nurse has participated in organizing a blood donation drive at a local community center. Which of the following individuals would most likely be disallowed from donating blood?
- A. A man who is 81 years of age
- B. A woman whose blood pressure is 88/51 mm Hg
- C. A man who donated blood 4 months ago
- D. A woman who has type 1 diabetes
Correct Answer: B
Rationale: For potential blood donors, systolic arterial BP should be 90 to 180 mm Hg, and the diastolic pressure should be 50 to 100 mm Hg. There is no absolute upper age limit. Donation 4 months ago does not preclude safe repeat donation and diabetes is not a contraindication.
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A nurse is caring for a patient who undergoing preliminary testing for a hematologic disorder. What sign or symptom most likely suggests a potential hematologic disorder?
- A. Sudden change in level of consciousness (LOC)
- B. Recurrent infections
- C. Anaphylaxis
- D. Severe fatigue
Correct Answer: D
Rationale: The most common indicator of hematologic disease is extreme fatigue. This is more common than changes in LOC, infections, or anaphylaxis.
A patient undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions?
- A. Safe transfusion for patients with a history of transfusion reactions
- B. Prevention of viral infections from another persons blood
- C. Avoidance of complications in patients with alloantibodies
- D. Prevention of alloimmunization
Correct Answer: B
Rationale: The primary advantage of autologous transfusions is the prevention of viral infections from another persons blood. Other secondary advantages include safe transfusion for patients with a history of transfusion reactions, prevention of alloimmunization, and avoidance of complications in patients with alloantibodies.
Which of the following circumstances would most clearly warrant autologous blood donation?
- A. The patient has type-O blood.
- B. The patient has sickle cell disease or a thalassemia.
- C. The patient has elective surgery pending.
- D. The patient has hepatitis C.
Correct Answer: C
Rationale: Autologous blood donation is useful for many elective surgeries where the potential need for transfusion is high. Type-O blood, hepatitis, sickle cell disease, and thalassemia are not clear indications for autologous donation.
A patients most recent blood work reveals low levels of albumin. This assessment finding should suggest the possibility of what nursing diagnosis?
- A. Risk for imbalanced fluid volume related to low albumin
- B. Risk for infection related to low albumin
- C. Ineffective tissue perfusion related to low albumin
- D. Impaired skin integrity related to low albumin
Correct Answer: A
Rationale: Albumin is particularly important for the maintenance of fluid balance within the vascular system. Deficiencies nearly always manifest as fluid imbalances. Tissue oxygenation and skin integrity are not normally affected. Low albumin does not constitute a risk for infection.
The nurses review of a patients most recent blood work reveals a significant increase in the number of band cells. The nurses subsequent assessment should focus on which of the following?
- A. Respiratory function
- B. Evidence of decreased tissue perfusion
- C. Signs and symptoms of infection
- D. Recent changes in activity tolerance
Correct Answer: C
Rationale: Ordinarily, band cells account for only a small percentage of circulating granulocytes, although their percentage can increase greatly under conditions in which neutrophil production increases, such as infection. This finding is not suggestive of problems with oxygenation and subsequent activity intolerance.