Nokea
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.
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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 nurse is preparing to administer a unit of platelets to an adult patient. When administering this blood product, which of the following actions should the nurse perform?
- A. Administer the platelets as rapidly as the patient can tolerate.
- B. Establish IV access as soon as the platelets arrive from the blood bank.
- C. Ensure that the patient has a patent central venous catheter.
- D. Aspirate 10 to 15 mL of blood from the patients IV immediately following the transfusion.
Correct Answer: A
Rationale: The nurse should infuse each unit of platelets as fast as patient can tolerate to diminish platelet clumping during administration. IV access should be established prior to obtaining the platelets from the blood bank. A central line is appropriate for administration, but peripheral IV access (22-gauge or larger) is sufficient. There is no need to aspirate after the transfusion.
A clients health history reveals daily consumption of two to three bottles of wine. The nurse should plan assessments and interventions in light of the patients increased risk for what hematologic disorder?
- A. Leukemia
- B. Anemia
- C. Thrombocytopenia
- D. Lymphoma
Correct Answer: B
Rationale: Heavy alcohol use is associated with numerous health problems, including anemia. Leukemia and lymphoma are not associated with alcohol use; RBC levels are typically affected more than platelet levels.
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.
A patient lives with a diagnosis of sickle cell anemia and receives frequent blood transfusions. The nurse should recognize the patients consequent risk of what complication of treatment?
- A. Hypovolemia
- B. Vitamin B12 deficiency
- C. Thrombocytopenia
- D. Iron overload
Correct Answer: D
Rationale: Patients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. These individuals are not at risk for hypovolemia and there is no consequent risk for low platelet or vitamin B12 levels.