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A patient is being prepared to receive a prescribed blood transfusion. What is the best way that the LPN can assist the health team to prevent a transfusion reaction?
- A. Monitor vital signs every 15 minutes.
- B. Warm blood to 98.6°F (37°C) before infusion.
- C. Administer diphenhydramine (Benadryl) before the infusion.
- D. Assist the registered nurse (RN) to identify correctly the patient and the blood product.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Identifying the patient and blood product is crucial to prevent transfusion reactions.
2. Matching the patient's identity with the blood product minimizes risk of incompatibility.
3. This step ensures the right blood type and product are administered, preventing serious reactions.
4. LPNs play a key role in assisting the RN in verifying and confirming patient and blood product identity.
Summary:
A: Monitoring vital signs is important but doesn't directly prevent transfusion reactions.
B: Warming blood can improve patient comfort but does not prevent reactions.
C: Administering Benadryl addresses possible allergic reactions but doesn't prevent incompatibility issues.
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A 16-year-old female patient with severe factor XI deficiency presents with acute appendicitis and requires urgent surgery. You are called by the surgeon, who wants to know what, if any, blood products or treatments are required to reduce the risk of perioperative bleeding. The patient weighs 62 kg. What should you tell him to administer?
- A. Cryoprecipitate (five units), which will likely raise her factor XI level to 20%
- B. Factor XI concentrate (20 units/kg), which will raise her factor XI level to 20%
- C. Fresh frozen plasma (20 mL/kg), which will raise her factor XI level to 20%
- D. Prothrombin complex concentrate (40 units/kg), which will raise her factor XI level to 20%
Correct Answer: C
Rationale: The correct answer is C: Fresh frozen plasma (20 mL/kg), which will raise her factor XI level to 20%. Fresh frozen plasma contains various clotting factors, including factor XI. In a patient with severe factor XI deficiency, administering fresh frozen plasma can increase factor XI levels and help reduce the risk of perioperative bleeding. The dose of 20 mL/kg is appropriate for this patient's weight of 62 kg. Cryoprecipitate (choice A) may contain factor XI but is not the optimal choice for raising factor XI levels specifically. Factor XI concentrate (choice B) would be ideal but is not commonly available, making fresh frozen plasma a more practical option. Prothrombin complex concentrate (choice D) primarily contains factors II, VII, IX, and X, but not factor XI, so it would not effectively raise factor XI levels in this patient.
A patient is being prepared to receive a prescribed blood transfusion. What is the best way that the LPN can assist the health team to prevent a transfusion reaction?
- A. Monitor vital signs every 15 minutes.
- B. Warm blood to 98.6°F (37°C) before infusion.
- C. Administer diphenhydramine (Benadryl) before the infusion.
- D. Assist the registered nurse (RN) to identify correctly the patient and the blood product.
Correct Answer: D
Rationale: The correct answer is D: Assist the registered nurse (RN) to identify correctly the patient and the blood product. This is crucial to prevent transfusion reactions as it ensures the right blood is given to the right patient. Misidentification can lead to severe complications. Monitoring vital signs (A) is important but doesn't directly prevent transfusion reactions. Warming blood (B) may improve patient comfort but doesn't prevent reactions. Administering diphenhydramine (C) is not a standard pre-transfusion medication and should not be given without specific orders. Identifying the patient and blood product correctly is the best way to prevent transfusion reactions.
An emergency department nurse is triaging a 77-year-old man who presents with uncharacteristic fatigue as well as back and rib pain. The patient denies any recent injuries. The nurse should recognize the need for this patient to be assessed for what health problem?
- A. Hodgkin disease
- B. Non-Hodgkin Lymphoma
- C. Multiple Myeloma
- D. Acute Thrombocytopenia
Correct Answer: C
Rationale: The correct answer is C: Multiple Myeloma. In this case, the patient's age, symptoms of fatigue, back, and rib pain without recent injuries are indicative of multiple myeloma. This condition is a type of cancer that affects plasma cells in the bone marrow, leading to bone pain and fatigue. Hodgkin disease and Non-Hodgkin Lymphoma typically present with lymph node enlargement rather than back and rib pain. Acute Thrombocytopenia would present with symptoms related to low platelet levels such as bleeding tendencies, not back and rib pain.
Peripheral bl. Picture is most useful in:
- A. NHL
- B. multiple myeloma
- C. myelodysplastic syndrome
- D. CML
Correct Answer: D
Rationale: The correct answer is D: CML. Peripheral blood picture is most useful in CML because it typically shows increased white blood cell count with left shift, basophilia, and presence of the Philadelphia chromosome. In contrast, A (NHL) primarily involves lymph nodes, B (multiple myeloma) shows monoclonal protein in serum/bone marrow, and C (myelodysplastic syndrome) presents with cytopenias and dysplastic changes in blood cells. Therefore, based on the specific findings seen in CML on peripheral blood, it is the most appropriate choice.
A nurse is assessing a dark-skinned client for pallor. What nursing assessment is best to assess for pallor in this client?
- A. Assess the conjunctiva of the eye.
- B. Have the patient open the hand widely.
- C. Look at the roof of the patient's mouth.
- D. Palpate for areas of mild swelling.
Correct Answer: A
Rationale: The correct answer is A: Assess the conjunctiva of the eye. Pallor is difficult to detect in dark-skinned individuals due to the lack of contrast. The conjunctiva of the eye provides a reliable area to assess for pallor as it is mucous membrane with blood vessels that can show changes in color. It is not accurate to assess for pallor by having the patient open the hand widely (B) as skin color on hands may vary. Looking at the roof of the mouth (C) may not accurately reflect pallor. Palpating for areas of mild swelling (D) does not assess for pallor, but rather for edema.