Nokea
A patient is being treated on the medical unit for a sickle cell crisis. The nurse's most recent assessment reveals an oral temperature of 100.5°F and a new onset of fine crackles on lung auscultation. What is the nurse's most appropriate action?
- A. Apply supplementary oxygen by nasal cannula.
- B. Administer bronchodilators by nebulizer.
- C. Liaise with the respiratory therapist and consider high-flow oxygen.
- D. Inform the primary care provider that the patient may have an infection.
Correct Answer: D
Rationale: Patients with sickle cell disease are highly susceptible to infection; thus any early signs of infection should be reported promptly. There is no evidence of respiratory distress, so oxygen therapy and bronchodilators are not indicated.
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A patient's absolute neutrophil count (ANC) is 440/mm3. But the nurse's assessment reveals no apparent signs or symptoms of infection. What action should the nurse prioritize when providing care for this patient?
- A. Meticulous hand hygiene
- B. Timely administration of antibiotics
- C. Provision of a nutrient-dense diet
- D. Maintaining a sterile care environment
Correct Answer: A
Rationale: Providing care for a patient with neutropenia requires that the nurse adhere closely to standard precautions and infection control procedures. Hand hygiene is central to such efforts. Prophylactic antibiotics are rarely used and it is not possible to provide a sterile environment for care. Nutrition is highly beneficial, but hand hygiene is the central aspect of care.
A night nurse is reviewing the next day's medication administration record (MAR) of a patient who has hemophilia. The nurse notes that the MAR specifies both oral and subcutaneous options for the administration of a PRN antiemetic. What is the nurse's best action?
- A. Ensure that the day nurse knows not to give the antiemetic.
- B. Contact the prescriber to have the subcutaneous option discontinued.
- C. Reassess the patient's need for antiemetics.
- D. Remove the subcutaneous route from the patient's MAR.
Correct Answer: B
Rationale: Injections must be avoided in patients with hemophilia. Consequently, the nurse should ensure that the prescriber makes the necessary change. The nurse cannot independently make a change to a patient's MAR in most cases. Facilitating the necessary change is preferable to deferring to the day nurse.
A patient, 25 years of age, comes to the emergency department complaining of excessive bleeding from a cut sustained when cleaning a knife. Blood work shows a prolonged PT but a vitamin K deficiency is ruled out. When assessing the patient, areas of ecchymosis are noted on other areas of the body. Which of the following is the most plausible cause of the patients signs and symptoms?
- A. Lymphoma
- B. Leukemia
- C. Hemophilia
- D. Hepatic dysfunction
Correct Answer: D
Rationale: Prolongation of the PT, unless it is caused by vitamin K deficiency, may indicate severe hepatic dysfunction. The majority of hemophiliacs are diagnosed as children. The scenario does not describe signs or symptoms of lymphoma or leukemia.
A patient with a history of atrial fibrillation has contacted the clinic saying that she has accidentally overdosed on her prescribed warfarin (Coumadin). The nurse should recognize the possible need for what antidote?
- A. IVIG
- B. Factor X
- C. Vitamin K
- D. Factor VIII
Correct Answer: C
Rationale: Vitamin K is administered as an antidote for warfarin toxicity.
A patient comes to the clinic complaining of fatigue and the health interview is suggestive of pica. Laboratory findings reveal a low serum iron level and a low ferritin level. With what would the nurse suspect that the patient will be diagnosed?
- A. Iron deficiency anemia
- B. Pernicious anemia
- C. Sickle cell anemia
- D. Hemolytic anemia
Correct Answer: A
Rationale: A low serum iron level, a low ferritin level, and symptoms of pica are associated with iron deficiency anemia. TIBC may also be elevated. None of the other anemias are associated with pica.