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A patient receiving blood begins complaining of severe chest pain and a feeling of warmth. What should the nurse do first?
- A. Call the physician.
- B. Administer diuretics as ordered.
- C. Discontinue the blood transfusion.
- D. Assess vital signs and cardiovascular status.
Correct Answer: C
Rationale: The correct first step is to discontinue the blood transfusion (Choice C) because the patient is experiencing symptoms of a transfusion reaction, such as chest pain and warmth. Stopping the transfusion is crucial to prevent further harm. Calling the physician (Choice A) can be done after discontinuing the transfusion. Administering diuretics (Choice B) is not appropriate for this situation. Assessing vital signs and cardiovascular status (Choice D) should be done after stopping the transfusion to monitor the patient's condition.
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A nurse is monitoring a client who is undergoing anticoagulant therapy with heparin. Which of the following findings should the nurse identify as a possible indication of hemorrhage?
- A. Rapid pulse
- B. Yellowing of the sclera
- C. Elevated blood pressure
- D. Pale-colored stools
Correct Answer: A
Rationale: The correct answer is A: Rapid pulse. When a client is undergoing anticoagulant therapy with heparin, the nurse should monitor for signs of hemorrhage. A rapid pulse can indicate internal bleeding, a common complication of anticoagulant therapy. Other choices such as B: Yellowing of the sclera, C: Elevated blood pressure, and D: Pale-colored stools are not typically associated with hemorrhage. Yellowing of the sclera may indicate jaundice, elevated blood pressure may be related to other conditions, and pale-colored stools may indicate liver or gallbladder issues. Rapid pulse is the most pertinent finding related to hemorrhage in this context.
A nurse is caring for a client who recently started alteplase therapy. The nurse should monitor the client for which of the following adverse effects?
- A. Bronchodilation
- B. Headache
- C. Edema
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Headache. Alteplase is a thrombolytic medication that can increase the risk of bleeding, including intracranial bleeding, leading to headaches. Monitoring for headaches is crucial to detect any signs of bleeding. Bronchodilation (A) is not a common adverse effect of alteplase. Edema (C) and hypertension (D) are also not typically associated with alteplase therapy. Monitoring for headache is essential for early detection of potentially life-threatening complications.
An adult patient has presented to the health clinic with a complaint of a firm, painless cervical lymph node. The patient denies any recent infectious diseases. What is the nurse's most appropriate response to the patient's complaint?
- A. Call 911.
- B. Promptly refer the patient for medical assessment.
- C. Facilitate a radiograph of the patient's neck and have the results forwarded to the patient's primary care provider.
- D. Encourage the patient to track the size of the lymph node and seek care in 1 week.
Correct Answer: B
Rationale: The correct answer is B: Promptly refer the patient for medical assessment. A firm, painless cervical lymph node in an adult without recent infectious diseases raises concern for potential serious underlying conditions such as malignancy. Referring the patient for medical assessment allows for proper evaluation, diagnosis, and timely intervention if needed. Calling 911 (choice A) is not necessary as the patient is not in immediate life-threatening danger. Facilitating a radiograph (choice C) may not provide sufficient information for a definitive diagnosis. Encouraging the patient to track the size and wait a week (choice D) can delay necessary medical evaluation and potentially worsen the condition if it is indeed concerning.
A nurse is caring for four clients. After reviewing today's laboratory results, which client would the nurse assess first?
- A. Client with an international normalized ratio of 2.8
- B. Client with a platelet count of 128,000/mm3 (128 x 109/L).
- C. Client with a prothrombin time (PT) of 28 seconds
- D. Client with a red blood cell count of 5.1 million/mcl. (5.1 x 1012/L)
Correct Answer: C
Rationale: The correct answer is C because a prothrombin time (PT) of 28 seconds indicates potential issues with blood clotting and can be a sign of bleeding disorders or liver dysfunction, requiring immediate assessment and intervention to prevent complications.
Choice A (INR of 2.8) is within the therapeutic range for clients on anticoagulant therapy, so it's not an immediate concern. Choice B (platelet count of 128,000/mm3) is low but not critically low, so it doesn't require immediate assessment. Choice D (red blood cell count of 5.1 million/mcl) is within the normal range and doesn't indicate urgent issues.
In summary, the nurse should assess the client with a PT of 28 seconds first due to the potential risk of bleeding or clotting disorders, while the other choices are not as urgent.
A nursing student wants to know why clients with chronic obstructive pulmonary disease tend to be polycythemic. What response by the nurse instructor is best?
- A. It is due to side effects of medications for bronchodilation.
- B. It is from overactive bone marrow in response to chronic disease.
- C. It combats the anemia caused by an increased metabolic rate.
- D. It compensates for tissue hypoxia caused by lung disease.
Correct Answer: D
Rationale: The correct answer is D because in chronic obstructive pulmonary disease (COPD), the lungs are unable to efficiently oxygenate the blood, leading to tissue hypoxia. Polycythemia is the body's compensatory mechanism to increase red blood cell production in an attempt to improve oxygen-carrying capacity to tissues. Choices A, B, and C are incorrect as polycythemia in COPD is primarily a response to tissue hypoxia rather than medication side effects, overactive bone marrow, or combating anemia related to increased metabolic rate.