Nokea
A patient's electronic health record notes that he has previously undergone treatment for secondary polycythemia. How should this aspect of the patient's history guide the nurse's subsequent assessment?
- A. The nurse should assess for recent blood donation.
- B. The nurse should assess for evidence of lung disease.
- C. The nurse should assess for a history of venous thromboembolism.
- D. The nurse should assess the patient for impaired renal function.
Correct Answer: B
Rationale: Any reduction in oxygenation, such as lung disease, can cause secondary polycythemia. Blood donation does not precipitate this problem and impaired renal function typically causes anemia, not polycythemia. A history of VTE is not a likely contributor.
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A client with several chronic health problems has been newly diagnosed with a qualitative platelet defect. What component of the patient's previous medication regimen may have contributed to the development of this disorder?
- A. Calcium carbonate
- B. Vitamin B12
- C. Aspirin
- D. Vitamin D
Correct Answer: C
Rationale: Aspirin may induce a platelet disorder. Even small amounts of aspirin reduce normal platelet aggregation, and the prolonged bleeding time lasts for several days after aspirin ingestion. Calcium, vitamin D, and vitamin B12 do not have the potential to induce a platelet defect.
A nurse is planning the care of a patient with a diagnosis of sickle cell disease who has been admitted for the treatment of an acute vaso-occlusive crisis. What nursing diagnosis should the nurse prioritize in the patient's plan of care?
- A. Risk for disuse syndrome related to ineffective peripheral circulation
- B. Functional urinary incontinence related to urethral occlusion
- C. Ineffective tissue perfusion related to thrombosis
- D. Ineffective thermoregulation related to hypothalamic dysfunction
Correct Answer: C
Rationale: There are multiple potential complications of sickle cell disease and sickle cell crises. Central among these, however, is the risk of thrombosis and consequent lack of tissue perfusion. Sickle cell crises are not normally accompanied by impaired thermoregulation or genitourinary complications. Risk for disuse syndrome is not associated with the effects of acute vaso-occlusive crisis.
A patient with a recent diagnosis of ITP has asked the nurse why the care team has not chosen to administer platelets, stating, â??I have low platelets, so why not give me a transfusion of exactly what I'm missing?â?? How should the nurse best respond?
- A. Transfused platelets usually aren't beneficial because they're rapidly destroyed in the body.
- B. A platelet transfusion often blunts your body's own production of platelets even further.
- C. Finding a matching donor for a platelet transfusion is exceedingly difficult.
- D. A very small percentage of the platelets in a transfusion are actually functional.
Correct Answer: A
Rationale: Despite extremely low platelet counts, platelet transfusions are usually avoided. Transfusions tend to be ineffective not because the platelets are nonfunctional but because the patient's antiplatelet antibodies bind with the transfused platelets, causing them to be destroyed. Matching the patient's blood type is not usually necessary for a platelet transfusion. Platelet transfusions do not exacerbate low platelet production.
A nurse is providing discharge education to a patient who has recently been diagnosed with a bleeding disorder. What topic should the nurse prioritize when teaching this patient?
- A. Avoiding buses, subways, and other crowded, public sites
- B. Avoiding activities that carry a risk for injury
- C. Keeping immunizations current
- D. Avoiding foods high in vitamin K
Correct Answer: B
Rationale: Patients with bleeding disorders need to understand the importance of avoiding activities that increase the risk of bleeding, such as contact sports. Immunizations involve injections and may be contraindicated for some patients. Patients with bleeding disorders do not need to normally avoid crowds. Foods high in vitamin K may be beneficial, not detrimental.
A patient with a pulmonary embolism is being treated with a heparin infusion. What diagnostic finding suggests to the nurse that treatment is effective?
- A. The patient's PT is within reference ranges.
- B. Arterial blood sampling tests positive for the presence of factor XIII.
- C. The patient's platelet level is below 100,000/mm3.
- D. The patient's activated partial thromboplastin time (aPTT) is 1.5 to 2.5 times the control value.
Correct Answer: D
Rationale: The therapeutic effect of heparin is monitored by serial measurements of the aPTT; the dose is adjusted to maintain the range at 1.5 to 2.5 times the laboratory control. Heparin dosing is not determined on the basis of platelet levels, the presence or absence of clotting factors, or PT levels.