Nokea
A nurse is preparing to hang a blood transfusion. Which action is most important?
- A. Documenting the transfusion
- B. Placing the client in NPO status
- C. Checking the blood product label
- D. Putting on a pair of gloves
Correct Answer: D
Rationale: To prevent bloodborne illness, the nurse should don a pair of gloves prior to hanging the blood, prioritizing infection control. Documentation is important but not the priority at this point. NPO status is not required, and checking the blood product label, while critical, is secondary to standard precautions like wearing gloves.
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A client has heparin-induced thrombocytopenia (HIT). The student nurse asks how this is treated. About what drugs does the nurse instructor teach? (Select all that apply.)
- A. Argatroban (Argatroban)
- B. Bivalirudin (Angiomax)
- C. Clopidogrel (Plavix)
- D. Lepirudin (Refludan)
- E. Methylprednisolone (Solu-Medrol)
Correct Answer: A,B,D
Rationale: Argatroban, bivalirudin, and lepirudin are direct thrombin inhibitors used to treat HIT. Clopidogrel is an antiplatelet agent, and methylprednisolone is a steroid, neither used for HIT.
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 frequent hospitalizations for leukemia and is worried about functioning as a parent to four small children. What action by the nurse would be most helpful?
- A. Assist the client to make sick day plans for household responsibilities.
- B. Help the client inform friends and family that they will have to help out.
- C. Refer the client to a social worker for family counseling.
- D. Provide information on community support groups.
Correct Answer: A
Rationale: Helping the client make sick day plans addresses their concern about parenting responsibilities during hospitalizations, offering practical support. Informing friends and family is less proactive, and while counseling or support groups may help, they are less immediate solutions.
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.
A client has Hodgkin's lymphoma, Ann Arbor stage Ib. For what manifestations should the nurse assess the client? (Select all that apply.)
- A. Headaches
- B. Night sweats
- C. Persistent fever
- D. Urinary frequency
- E. Weight loss
Correct Answer: B,C,E
Rationale: In Ann Arbor stage Ib, Hodgkin's lymphoma may present with systemic symptoms like night sweats, persistent fever, and weight loss, known as B symptoms. Headaches and urinary frequency are not typical manifestations of this stage.