Nokea
A nurse is caring for four clients. After reviewing today's laboratory results, which client should the nurse see first?
- A. Client with an international normalized ratio of 2.8
- B. Client with a platelet count of 128000/mm³
- C. Client with a prothrombin time (PT) of 28 seconds
- D. Client with a red blood cell count of 5.1 million/L
Correct Answer: C
Rationale: The correct answer is C because a prothrombin time (PT) of 28 seconds indicates a prolonged clotting time, putting the client at risk for bleeding. This requires immediate assessment and intervention to prevent complications.
Choice A (INR of 2.8) is within the therapeutic range for clients on anticoagulant therapy, so it does not require immediate attention.
Choice B (platelet count of 128000/mm³) is low but not critically low enough to warrant immediate action unless there are signs of active bleeding.
Choice D (red blood cell count of 5.1 million/L) is within normal limits and does not indicate an urgent issue.
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A nursing student wants to know why clients with chronic obstructive pulmonary disease tend to be polycythemic. What response by the nurse instructor is best?
- A. It is due to side effects of medications for bronchodilation.
- B. It is from overactive bone marrow in response to chronic disease.
- C. It combats the anemia caused by an increased metabolic rate.
- D. It compensates for tissue hypoxia caused by lung disease.
Correct Answer: D
Rationale: The correct answer is D because in chronic obstructive pulmonary disease (COPD), the lungs are unable to efficiently oxygenate the blood, leading to tissue hypoxia. Polycythemia is the body's compensatory mechanism to increase red blood cell production in an attempt to improve oxygen-carrying capacity to tissues. Choices A, B, and C are incorrect as polycythemia in COPD is primarily a response to tissue hypoxia rather than medication side effects, overactive bone marrow, or combating anemia related to increased metabolic rate.
A newborn infant develops jaundice on day of life 2. Labs are drawn, and she has a hemoglobin of 7.4 g/dL with a reticulocyte count of 8%. Upon peripheral blood smear review, she is found to have bizarre red cell forms with significant polkilocytosis. Although her parents have normal blood counts, on review of their peripheral blood smears, they both have a moderate number of ovalocytes. Which of the following is the most likely cause of the infant's red cell findings?
- A. She has an autosomal dominant ankyrin mutation from one of her parents causing hereditary spherocytosis.
- B. She has inherited band 3 variants from each parent and will likely need a splenectomy after she turns 5 years old.
- C. She has inherited an alpha-spectrin mutation from both of her parents and may experience an improvement in her anemia over time.
- D. She has inherited a PKLR variant from each parent, and enzyme testing will be consistent with her diagnosis of pyruvate kinase deficiency.
Correct Answer: C
Rationale: The correct answer is C because the infant likely has hereditary elliptocytosis, an autosomal dominant disorder caused by mutations in the alpha-spectrin gene. Ovalocytes and polkilocytosis are characteristic of this condition. Since both parents have ovalocytes, it is likely that the infant inherited mutations from each parent, resulting in a more severe presentation. Anemia in hereditary elliptocytosis can improve over time due to compensatory mechanisms. Choices A, B, and D are incorrect as they describe different genetic disorders (hereditary spherocytosis, hereditary stomatocytosis, and pyruvate kinase deficiency, respectively) and do not match the clinical and family history provided.
When reviewing the chemistry panel of a newly diagnosed patient with acute lymphoblastic leukemia who is lethargic, complaining of flank pain, and experiencing nausea and vomiting, which of the following would you expect to see?
- A. Potassium 4.5 mmol/L, phosphorus 8 mg/dL, uric acid 7 mg/dL, calcium 9.0 mg/dL, BUN 12 mg/dL
- B. Potassium 6.5 mmol/L, phosphorus 8 mg/dL, uric acid 9 mg/dL, calcium 10 mg/dL, BUN 14 mg/dL
- C. Potassium 4 mmol/L, phosphorus 9 mg/dL, uric acid 10 mg/dL, calcium 10 mg/dL, BUN 10 mg/dL
- D. Potassium 7 mmol/L, phosphorus 12 mg/dL, uric acid 10 mg/dL, calcium 7 mg/dL, BUN 25 mg/dL
Correct Answer: D
Rationale: Step-by-step rationale:
1. Lethargy, flank pain, nausea, vomiting in leukemia can suggest tumor lysis syndrome (TLS).
2. TLS can cause hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia, and elevated BUN.
3. Choice D has the highest potassium, phosphorus, uric acid, and BUN levels, and the lowest calcium level.
4. Therefore, choice D is the most consistent with the expected lab findings in tumor lysis syndrome.
Summary:
- Choice A has normal potassium, phosphorus, uric acid, calcium levels, and lower BUN.
- Choice B has high potassium but normal phosphorus, uric acid, calcium, and slightly elevated BUN.
- Choice C has low potassium, normal phosphorus, and elevated uric acid, calcium, and BUN.
- Choice D aligns most closely with the expected lab findings in tumor lysis syndrome due to the pattern of
After seven days of treatment with sulfonamides, a patient's hemoglobin had decreased from 14.7 gm/100ml to 10gm/100ml. The most likely cause of hemolysis in this patient is
- A. Sickle cell disease
- B. Thalassemia minor
- C. Hereditary spherocytosis
- D. Glucose 6-phosphate dehydrogenase deficiency (G6PD)
Correct Answer: D
Rationale: The correct answer is D: Glucose 6-phosphate dehydrogenase deficiency (G6PD). Sulfonamides can trigger hemolysis in patients with G6PD deficiency due to oxidative stress on red blood cells. G6PD enzyme deficiency impairs the ability of red blood cells to combat oxidative damage, leading to hemolysis. In this case, the patient's hemoglobin decreased significantly after sulfonamide treatment, indicating red blood cell destruction. The other choices (A: Sickle cell disease, B: Thalassemia minor, C: Hereditary spherocytosis) are not directly associated with sulfonamide-induced hemolysis and would not explain the observed decrease in hemoglobin levels after treatment.
A 13-year-old Hispanic girl is found to have a WBC count of 6,500/mm3 with 40% Auer rod–containing granular blasts that, by flow cytometry, express very bright CD33 but are negative for human leukocyte antigen–DR isotype (HLA-DR). She is oozing blood around her peripheral IV site. Coagulation studies reveal an international normalized ratio (INR) of 3.4, a fibrinogen of 170, and a markedly elevated D-dimer. Marrow aspirate shows nearly 90% blasts with a similar morphology. You send the marrow to the fluorescence in situ hybridization (FISH) lab and request STAT testing for the most likely recurrent genetic abnormality based on the clinical presentation. How do you plan to initiate therapy?
- A. Perform a lumbar puncture to determine leukemic involvement, then proceed with induction chemotherapy.
- B. Begin therapy with all-trans retinoic acid (ATRA) immediately while aggressively managing coagulopathy with blood product support.
- C. Start dexamethasone and hydroxyurea immediately while aggressively managing coagulopathy with blood product support.
- D. Start induction chemotherapy, obtain HLA typing, and start a donor search because of the poor prognosis associated with this leukemic phenotype.
Correct Answer: B
Rationale: The correct answer is B because the clinical presentation suggests acute promyelocytic leukemia (APL). APL is characterized by Auer rod-containing granular blasts, which are positive for CD33 and negative for HLA-DR. The presence of coagulopathy with elevated D-dimer and oozing blood indicates a high risk of disseminated intravascular coagulation (DIC), a common complication of APL. Immediate treatment with all-trans retinoic acid (ATRA) is crucial in APL to induce differentiation of the leukemic cells and prevent further coagulopathy. Aggressively managing the coagulopathy with blood product support is also important to stabilize the patient.
Choice A is incorrect because a lumbar puncture is not necessary for APL diagnosis, and immediate induction chemotherapy with ATRA is the standard of care. Choice C is incorrect because dexamethasone and hydroxyurea are not the first-line therapies for APL.