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 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.
The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered?
- A. Platelet count
- B. Neutrophil count
- C. Hemoglobin level
- D. White blood cell count
Correct Answer: C
Rationale: The correct answer is C, 'Hemoglobin level.' Pallor of the skin and nail beds is a sign of anemia, which is characterized by a low hemoglobin level. Anemia is a condition where there is a decreased number of red blood cells or hemoglobin in the blood, leading to reduced oxygen-carrying capacity. Checking the hemoglobin level would help confirm the presence and severity of anemia, guiding further diagnostic and treatment interventions. Choices A, B, and D are incorrect because platelet count, neutrophil count, and white blood cell count are not typically associated with the pallor of the skin and nail beds, which are more indicative of an underlying anemic condition.
The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect?
- A. Yellow-tinged sclerae
- B. Shiny, smooth tongue
- C. Numbness of the extremities
- D. Gum bleeding and tenderness
Correct Answer: C
Rationale: The correct answer is C: Numbness of the extremities. Numbness of the extremities is a common finding in patients with pernicious anemia, which is caused by cobalamin (vitamin B12) deficiency. This deficiency affects the peripheral nervous system, leading to neurological symptoms like numbness and tingling in the extremities. Choices A, B, and D are incorrect: Yellow-tinged sclerae is more indicative of jaundice or liver dysfunction, a shiny smooth tongue is seen in conditions like glossitis, and gum bleeding and tenderness are associated with periodontal disease or vitamin C deficiency, not pernicious anemia.
A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test?
- A. Bone marrow biopsy
- B. Abdominal ultrasound
- C. Complete blood count (CBC)
- D. Activated partial thromboplastin time (aPTT)
Correct Answer: A
Rationale: In the case of a patient with pancytopenia of unknown origin, a bone marrow biopsy is usually indicated to determine the cause. A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. Abdominal ultrasound (Choice B) is not typically used to diagnose pancytopenia. A Complete Blood Count (CBC) (Choice C) is a routine blood test and does not require a specific consent form. Activated Partial Thromboplastin Time (aPTT) (Choice D) is a coagulation test and not typically performed to diagnose pancytopenia.
Which task for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?
- A. Assessing the patient for signs and symptoms of infection
- B. Teaching the patient the purpose of neutropenic precautions
- C. Administering subcutaneous filgrastim (Neupogen) injection
- D. Developing a discharge teaching plan for the patient and family
Correct Answer: C
Rationale: The correct answer is C because administering subcutaneous medications falls within the education and scope of practice of an LPN/LVN. Assessing the patient for signs and symptoms of infection, teaching the patient, and developing a discharge plan are tasks that require an RN level of education and scope of practice. LPN/LVNs can assist in patient care, but tasks that involve assessment, teaching, and care planning are typically the responsibility of an RN.