Nokea
A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to
- A. administer oxygen therapy at a high flow rate
- B. obtain a urine specimen to send to the laboratory
- C. notify the healthcare provider about the symptoms
- D. disconnect the transfusion and infuse normal saline
Correct Answer: D
Rationale: The patient's symptoms, back pain, and difficulty breathing after the transfusion indicate a possible acute hemolytic reaction, a severe transfusion reaction. The priority action in this situation is to discontinue the transfusion immediately to prevent further complications. Infusing normal saline helps maintain the patient's intravascular volume and prevent renal damage. Administering oxygen or obtaining a urine specimen is not the most urgent action and could delay essential treatment. Notifying the healthcare provider is important but should come after ensuring the patient's safety by stopping the blood transfusion.
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The nurse is reviewing laboratory results and notes a patient's activated partial thromboplastin time (aPTT) level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication?
- A. Aspirin
- B. Heparin
- C. Warfarin
- D. Erythropoietin
Correct Answer: B
Rationale: The correct answer is B: Heparin. An activated partial thromboplastin time (aPTT) level of 28 seconds indicates a prolonged time, which is associated with heparin administration. Heparin is an anticoagulant medication that affects the intrinsic pathway of the coagulation cascade, leading to an increased aPTT. Aspirin (choice A) affects platelet aggregation and does not directly impact aPTT. Warfarin (choice C) affects the extrinsic pathway of the coagulation cascade and is monitored using the international normalized ratio (INR), not aPTT. Erythropoietin (choice D) is not related to coagulation parameters.
The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient?
- A. Are you taking any oral contraceptives?
- B. Have you been prescribed antiseizure drugs?
- C. Do you take medication containing salicylates?
- D. How long have you been taking antihypertensive drugs?
Correct Answer: C
Rationale: The correct answer is C: 'Do you take medication containing salicylates?' Petechiae are tiny, pinpoint, red or purple spots on the skin due to bleeding under the skin. Salicylates, which are found in medications like aspirin, interfere with platelet function and can lead to petechiae and ecchymoses. Asking about salicylate-containing medications is crucial in this situation. Choices A, B, and D are incorrect because they are not directly related to the development of petechiae.
During a physical assessment, the nurse examines the lymph nodes of a patient. Which assessment finding would be of most concern to the nurse?
- A. A 2-cm nontender supraclavicular node
- B. A 1-cm mobile and nontender axillary node
- C. An inability to palpate any superficial lymph nodes
- D. Firm inguinal nodes in a patient with an infected foot
Correct Answer: A
Rationale: The correct answer is A. A 2-cm nontender supraclavicular node is of most concern because enlarged and nontender nodes in this area are highly suggestive of malignancies such as lymphoma. Choice B is less concerning as a 1-cm mobile and nontender axillary node is usually benign. Choice C, an inability to palpate any superficial lymph nodes, could be due to factors like obesity or edema, but it is not necessarily a cause for immediate concern. Choice D, firm inguinal nodes in a patient with an infected foot, may indicate a local reaction to infection rather than a systemic issue related to malignancy.
Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia?
- A. Potential complication: seizures
- B. Potential complication: infection
- C. Potential complication: neurogenic shock
- D. Potential complication: pulmonary edema
Correct Answer: B
Rationale: The correct answer is B: Potential complication: infection. Patients with idiopathic aplastic anemia have pancytopenia, which puts them at a high risk for infections due to decreased production of all blood cells (red blood cells, white blood cells, and platelets). Infection is a significant concern in these patients. Choices A, C, and D are incorrect because seizures, neurogenic shock, and pulmonary edema are not typically associated with idiopathic aplastic anemia. While seizures can occur in some conditions that affect the brain, neurogenic shock is related to spinal cord injury, and pulmonary edema is more commonly seen in conditions like heart failure.
The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the
- A. Schilling test
- B. bilirubin level
- C. gastric analysis
- D. stool occult blood
Correct Answer: B
Rationale: The correct answer is B: bilirubin level. Jaundice, characterized by scleral jaundice, is caused by the elevation of bilirubin levels associated with red blood cell hemolysis. Checking the bilirubin level in the laboratory results will help assess the severity of jaundice in the patient. Choices A, C, and D are incorrect because the Schilling test is used to assess vitamin B12 absorption, gastric analysis is used to evaluate gastric function, and stool occult blood is used to detect hidden blood in the stool, which are not directly related to evaluating jaundice in a patient with hemolytic anemia.