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A patients diagnosis of atrial fibrillation has prompted the primary care provider to prescribe warfarin (Coumadin), an anticoagulant. When assessing the therapeutic response to this medication, what is the nurses most appropriate action?
- A. Assess for signs of myelosuppression.
- B. Review the patients platelet level.
- C. Assess the patients capillary refill time.
- D. Review the patients international normalized ratio (INR).
Correct Answer: D
Rationale: The INR and aPTT serve as useful screening tools for evaluating a patients clotting ability and to monitor the therapeutic effectiveness of anticoagulant medications. The patients platelet level is not normally used as a short-term indicator of anticoagulation effectiveness. Assessing the patient for signs of myelosuppression and capillary refill time does not address the effectiveness of anticoagulants.
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The nurse is describing the role of plasminogen in the clotting cascade. Where in the body is plasminogen present?
- A. Myocardial muscle tissue
- B. All body fluids
- C. Cerebral tissue
- D. Venous and arterial vessel walls
Correct Answer: B
Rationale: Plasminogen, which is present in all body fluids, circulates with fibrinogen. Plasminogen is found in body fluids, not tissue.
A nurse at a blood donation clinic has completed the collection of blood from a woman. The woman states that she feels lightheaded and she appears visibly pale. What is the nurses most appropriate action?
- A. Help her into a sitting position with her head lowered below her knees.
- B. Administer supplementary oxygen by nasal prongs.
- C. Obtain a full set of vital signs.
- D. Inform a physician or other primary care provider.
Correct Answer: A
Rationale: A donor who appears pale or complains of faintness should immediately lie down or sit with the head lowered below the knees. He or she should be observed for another 30 minutes. There is no immediate need for a physicians care. Supplementary oxygen may be beneficial, but may take too much time to facilitate before a syncopal episode. Repositioning must precede assessment of vital signs.
An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction?
- A. Ensure that blood components are never infused at a rate greater than 125 mL/hr.
- B. Administer prophylactic antihistamines prior to all blood transfusions.
- C. Establish baseline vital signs for all patients receiving transfusions.
- D. Be vigilant in identifying the patient and the blood component.
Correct Answer: D
Rationale: The most common causes of acute hemolytic reaction are errors in blood component labeling and patient identification that result in the administration of an ABO-incompatible transfusion. Actions to address these causes are necessary in all health care settings. Prophylactic antihistamines are not normally administered, and would not prevent acute hemolytic reactions. Similarly, baseline vital signs and slow administration will not prevent this reaction.
A clients health history reveals daily consumption of two to three bottles of wine. The nurse should plan assessments and interventions in light of the patients increased risk for what hematologic disorder?
- A. Leukemia
- B. Anemia
- C. Thrombocytopenia
- D. Lymphoma
Correct Answer: B
Rationale: Heavy alcohol use is associated with numerous health problems, including anemia. Leukemia and lymphoma are not associated with alcohol use; RBC levels are typically affected more than platelet levels.
The nurse is describing normal RBC physiology to a patient who has a diagnosis of anemia. The nurse should explain that the RBCs consist primarily of which of the following?
- A. Plasminogen
- B. Hemoglobin
- C. Hematocrit
- D. Fibrin
Correct Answer: B
Rationale: Mature erythrocytes consist primarily of hemoglobin, which contains iron and makes up 95% of the cell mass. RBCs are not made of fibrin or plasminogen. Hematocrit is a measure of RBC volume in whole blood.