Nokea
A patient receiving blood complains of dyspnea. The nurse auscultates the patient's lungs and finds crackles that were not present before the start of the transfusion. Which type of reaction should the nurse suspect?
- A. Urticarial
- B. Hemolytic
- C. Anaphylactic
- D. Circulatory overload
Correct Answer: D
Rationale: The correct answer is D: Circulatory overload. Dyspnea and crackles post-transfusion indicate fluid overload, not an immune response. Step 1: Rule out urticarial (itching/rash) and anaphylactic (rapid onset, hypotension) reactions due to the absence of these symptoms. Step 2: Hemolytic reactions involve destruction of red blood cells, leading to hemoglobinuria and shock. Step 3: Circulatory overload results from an excessive volume of blood given, leading to pulmonary edema and crackles. In this case, the symptoms align with circulatory overload, making it the most likely reaction.
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Heparin is an anticoagulant produced by the basophils. The most likely mechanism heparin prevents blood clotting is by
- A. Inhibiting the formation of vitamin K-dependent clotting factors
- B. Preventing the activation of platelets
- C. Preventing the aggregation of platelets
- D. Binding to antithrombin III to inactivate thrombin
Correct Answer: D
Rationale: The correct answer is D because heparin binds to antithrombin III, enhancing its ability to inactivate thrombin. This prevents the conversion of fibrinogen to fibrin, thereby inhibiting blood clot formation. Choices A and B are incorrect because heparin does not affect vitamin K-dependent clotting factors or platelet activation. Choice C is incorrect because heparin does not directly prevent platelet aggregation.
A patient with a bleeding disorder is prescribed an infusion of plasma. What should the nurse explain as being the purpose of this infusion?
- A. Contains clotting factors
- B. Carries oxygen to the tissues
- C. Supports cellular metabolism
- D. Removes waste products from cells
Correct Answer: A
Rationale: The correct answer is A: Contains clotting factors. Plasma is the liquid component of blood that contains essential clotting factors necessary for blood coagulation. This infusion helps replenish clotting factors in patients with bleeding disorders, aiding in the formation of blood clots to stop bleeding. Choice B is incorrect as plasma does not carry oxygen; that is the role of red blood cells. Choice C is incorrect as plasma does not directly support cellular metabolism; that is the role of nutrients. Choice D is incorrect as plasma does not remove waste products; that is the role of the kidneys and liver.
A patient who is taking warfarin (Coumadin) 5 mg daily has an international normalized ratio (INR) of 2.5. It is time to administer the next dose of Coumadin. What should the nurse do?
- A. Notify the physician STAT.
- B. Hold the dose of Coumadin.
- C. Prepare to administer vitamin K.
- D. Administer the daily Coumadin as ordered.
Correct Answer: D
Rationale: The correct answer is D: Administer the daily Coumadin as ordered. A therapeutic INR range for patients on warfarin is typically between 2-3. A patient with an INR of 2.5 is within this range, indicating that their blood is adequately anticoagulated. Therefore, the next dose of Coumadin should be administered as prescribed to maintain the therapeutic effect. Holding the dose (B) may lead to subtherapeutic anticoagulation, and notifying the physician (A) is not necessary as the INR is within range. Administering vitamin K (C) is indicated for patients with a high INR and signs of bleeding, which is not the case here.
A nurse is caring for a client who is about to begin taking aspirin to reduce the risk of a cardiovascular event. The nurse should identify that the drug inhibits platelet aggregation by which of the following mechanisms?
- A. Activating thromboxane A2
- B. Blocking adenosine diphosphate receptor agonists
- C. Suppressing specific clotting factors
- D. Inhibiting cyclooxygenase action in platelets
Correct Answer: D
Rationale: The correct answer is D: Inhibiting cyclooxygenase action in platelets. Aspirin works by irreversibly inhibiting cyclooxygenase, specifically COX-1, in platelets. By inhibiting COX-1, aspirin prevents the formation of thromboxane A2, which is a potent platelet aggregator. This action reduces platelet aggregation and ultimately decreases the risk of clot formation leading to a cardiovascular event.
Choice A is incorrect because aspirin does not activate thromboxane A2, but rather inhibits its formation. Choice B is incorrect as aspirin does not block adenosine diphosphate receptors. Choice C is incorrect as aspirin does not suppress specific clotting factors, but rather inhibits platelet function through the mechanism described above.
A patient receiving blood complains of dyspnea. The nurse auscultates the patient's lungs and finds crackles that were not present before the start of the transfusion. Which type of reaction should the nurse suspect?
- A. Urticarial
- B. Hemolytic
- C. Anaphylactic
- D. Circulatory overload
Correct Answer: D
Rationale: The correct answer is D: Circulatory overload. This type of reaction occurs when the patient receives blood too quickly, leading to fluid overload in the circulatory system. The dyspnea and crackles are indicative of pulmonary edema, a common symptom of circulatory overload. Urticarial reaction (choice A) presents with hives, not dyspnea. Hemolytic reaction (choice B) involves the destruction of red blood cells, not fluid overload. Anaphylactic reaction (choice C) is a severe allergic reaction that includes symptoms like hives, swelling, and hypotension, but not typically pulmonary edema.