Nokea
A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take?
- A. Give the PRN diphenhydramine
- B. Send a urine specimen to the laboratory
- C. Administer PRN acetaminophen (Tylenol)
- D. Draw blood for a new type and crossmatch
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to
- A. provide a diet high in vitamin K
- B. alternate periods of rest and activity
- C. teach the patient how to avoid injury
- D. place the patient on protective isolation
Correct Answer: B
Rationale: In severe hemolytic anemia, the priority nursing intervention is to alternate periods of rest and activity. This approach helps to balance activity levels to prevent excessive fatigue while promoting mobility and preventing complications such as muscle weakness or deconditioning. Providing a diet high in vitamin K (choice A) is not directly related to managing hemolytic anemia. Teaching the patient how to avoid injury (choice C) is important but may not be the immediate priority. Placing the patient on protective isolation (choice D) is not indicated for hemolytic anemia, as it is not a contagious condition.
The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)?
- A. Verify the patient identification (ID) according to hospital policy
- B. Obtain the temperature, blood pressure, and pulse before the transfusion
- C. Double-check the product numbers on the PRBCs with the patient ID band
- D. Monitor the patient for shortness of breath or chest pain during the transfusion
Correct Answer: B
Rationale: The correct answer is B. Unlicensed assistive personnel (UAP) can obtain the temperature, blood pressure, and pulse before a transfusion as their education includes measurement of vital signs. UAP would then report the vital signs to the registered nurse (RN). Option A is typically a nursing responsibility to ensure patient safety and avoid errors in patient identification. Option C involves cross-checking important details and ensuring accuracy, which is usually performed by nursing staff to prevent errors. Option D requires monitoring for potential adverse reactions during the transfusion, which is a nursing responsibility due to the need for assessment and intervention in case of complications.
Which information shown in the table below about a patient who has just arrived in the emergency department is most urgent for the nurse to communicate to the healthcare provider?
- A. Heart rate
- B. Platelet count
- C. Abdominal pain
- D. White blood cell count
Correct Answer: B
Rationale: The correct answer is B: Platelet count. The platelet count is severely decreased, indicating a risk for spontaneous bleeding, which is a critical condition requiring immediate attention. While heart rate, abdominal pain, and white blood cell count are important, a severely decreased platelet count poses a more imminent threat to the patient's health and requires urgent communication to the healthcare provider. The nurse should prioritize addressing this potentially life-threatening issue to ensure prompt intervention and management.
A patient who has immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the healthcare provider before obtaining and administering platelets?
- A. Platelet count is 42,000/µL
- B. Petechiae are present on the chest
- C. Blood pressure (BP) is 94/56 mm Hg
- D. Blood is oozing from the venipuncture site
Correct Answer: A
Rationale: The correct answer is A. Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/µL unless the patient is actively bleeding. In this scenario, the platelet count of 42,000/µL is not significantly low to warrant a platelet transfusion without active bleeding. Consulting with the healthcare provider is essential before giving the transfusion to ensure the appropriateness of the treatment. Choices B, C, and D are not directly related to the need for consulting before a platelet transfusion. Petechiae, low blood pressure, and oozing from the venipuncture site are common findings in patients with ITP and may not necessarily contraindicate a platelet transfusion at this platelet count.
A patient's complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding?
- A. Have you had any recent weight loss?
- B. Do you have any history of lung disease?
- C. Have you noticed any dark or bloody stools?
- D. What is your dietary intake of meats and proteins?
Correct Answer: B
Rationale: The correct answer is B: "Do you have any history of lung disease?" The elevated hemoglobin and hematocrit levels suggest polycythemia, which can be seen in conditions like chronic obstructive pulmonary disease (COPD). Option A is less relevant as weight loss is not typically associated with these blood count findings. Option C is more indicative of gastrointestinal bleeding rather than a respiratory issue. Option D focuses on dietary factors, which are less likely to cause such significant elevations in hemoglobin and hematocrit levels as seen in this case.