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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.
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A nurse has participated in organizing a blood donation drive at a local community center. Which of the following individuals would most likely be disallowed from donating blood?
- A. A man who is 81 years of age
- B. A woman whose blood pressure is 88/51 mm Hg
- C. A man who donated blood 4 months ago
- D. A woman who has type 1 diabetes
Correct Answer: B
Rationale: For potential blood donors, systolic arterial BP should be 90 to 180 mm Hg, and the diastolic pressure should be 50 to 100 mm Hg. There is no absolute upper age limit. Donation 4 months ago does not preclude safe repeat donation and diabetes is not a contraindication.
A patient on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurses most appropriate action?
- A. Apply an icepack to the blood that remains to be infused.
- B. Discontinue the remainder of the PRBC transfusion and inform the physician.
- C. Disconnect the bag of PRBCs, cool for 30 minutes and then administer.
- D. Administer the remaining PRBCs by the IV direct (IV push) route.
Correct Answer: B
Rationale: Because of the risk of infection, a PRBC transfusion should not exceed 4 hours. Remaining blood should not be transfused, even if it is cooled. Blood is not administered by the IV direct route.
A patient has been scheduled for a bone marrow biopsy and admits to the nurse that she is worried about the pain involved with the procedure. What patient education is most accurate?
- A. Youll be given painkillers before the test, so there wont likely be any pain?
- B. Youll feel some pain when the needle enters your skin, but none when the needle enters the bone because of the absence of nerves in bone.
- C. Most people feel some brief, sharp pain when the needle enters the bone.
- D. Ill be there with you, and Ill try to help you keep your mind off the pain.
Correct Answer: C
Rationale: Patients typically feel a pressure sensation as the needle is advanced into position. The actual aspiration always causes sharp, but brief pain, resulting from the suction exerted as the marrow is aspirated into the syringe; the patient should be warned about this. Stating, Ill try to help you keep your mind off the pain may increase the patients fears of pain, because this does not help the patient know what to expect.
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.
A nurse is caring for a patient who undergoing preliminary testing for a hematologic disorder. What sign or symptom most likely suggests a potential hematologic disorder?
- A. Sudden change in level of consciousness (LOC)
- B. Recurrent infections
- C. Anaphylaxis
- D. Severe fatigue
Correct Answer: D
Rationale: The most common indicator of hematologic disease is extreme fatigue. This is more common than changes in LOC, infections, or anaphylaxis.