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A patient is receiving a blood transfusion and complains of a new onset of slight dyspnea. The nurses rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurses most appropriate action?
- A. Slow the infusion rate and monitor the patient closely.
- B. Discontinue the transfusion and begin resuscitation.
- C. Pause the transfusion and administer a 250 mL bolus of normal saline.
- D. Discontinue the transfusion and administer a beta-blocker, as ordered.
Correct Answer: A
Rationale: The patient is showing early signs of hypervolemia; the nurse should slow the infusion rate and assess the patient closely for any signs of exacerbation. At this stage, discontinuing the transfusion is not necessary. A bolus would worsen the patients fluid overload.
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A patient lives with a diagnosis of sickle cell anemia and receives frequent blood transfusions. The nurse should recognize the patients consequent risk of what complication of treatment?
- A. Hypovolemia
- B. Vitamin B12 deficiency
- C. Thrombocytopenia
- D. Iron overload
Correct Answer: D
Rationale: Patients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. These individuals are not at risk for hypovolemia and there is no consequent risk for low platelet or vitamin B12 levels.
A patients electronic health record states that the patient receives regular transfusions of factor IX. The nurse would be justified in suspecting that this patient has what diagnosis?
- A. Leukemia
- B. Hemophilia
- C. Hypoproliferative anemia
- D. Hodgkins lymphoma
Correct Answer: B
Rationale: Administration of clotting factors is used to treat diseases where these factors are absent or insufficient; hemophilia is among the most common of these diseases. Factor IX is not used in the treatment of leukemia, lymphoma, or anemia.
A patient is scheduled for a splenectomy. During discharge education, what teaching point should the nurse prioritize?
- A. The importance of adhering to prescribed immunosuppressant therapy
- B. The need to report any signs or symptoms of infection promptly
- C. The need to ensure adequate folic acid, iron, and vitamin B12 intake
- D. The importance of limiting activity postoperatively to prevent hemorrhage
Correct Answer: B
Rationale: After splenectomy, the patient is instructed to seek prompt medical attention if even relatively minor symptoms of infection occur. Often, patients with high platelet counts have even higher counts after splenectomy, which can predispose them to serious thrombotic or hemorrhagic problems. However, this increase is usually transient and therefore often does not warrant additional treatment. Dietary modifications are not normally necessary and immunosuppressants would be strongly contraindicated.
A patients most recent blood work reveals low levels of albumin. This assessment finding should suggest the possibility of what nursing diagnosis?
- A. Risk for imbalanced fluid volume related to low albumin
- B. Risk for infection related to low albumin
- C. Ineffective tissue perfusion related to low albumin
- D. Impaired skin integrity related to low albumin
Correct Answer: A
Rationale: Albumin is particularly important for the maintenance of fluid balance within the vascular system. Deficiencies nearly always manifest as fluid imbalances. Tissue oxygenation and skin integrity are not normally affected. Low albumin does not constitute a risk for infection.
A patient is receiving the first of two ordered units of PRBCs. Shortly after the initiation of the transfusion, the patient complains of chills and experiences a sharp increase in temperature. What is the nurses priority action?
- A. Position the patient in high Fowlers.
- B. Discontinue the transfusion.
- C. Auscultate the patients lungs.
- D. Obtain a blood specimen from the patient.
Correct Answer: B
Rationale: Stopping the transfusion is the first step in any suspected transfusion reaction. This must precede other assessments and interventions, including repositioning, chest auscultation, and collecting specimens.