Nokea
A teenaged client with hemophilia sustains a leg laceration after falling off a skateboard and is brought to the emergency department. The laceration is bleeding profusely even with direct pressure to the site. What does the nurse anticipate will be prescribed for administration to control bleeding?
- A. Fresh frozen plasma
- B. A colloid solution such as hetastarch (Hespan)
- C. A crystalloid solution such as lactated Ringer's
- D. Albumin
Correct Answer: A
Rationale: Treatment includes transfusion of fresh blood, frozen plasma, factor VIII concentrate, and anti-inhibitor coagulant complex for hemophilia A, factor IX concentrate for hemophilia B, factor XI for hemophilia C, and the application of thrombin or fibrin to the bleeding area. Other measures used to help control bleeding are the administration of fresh frozen plasma, aminocaproic acid that helps to hold a clot in place once it has formed, direct pressure over the bleeding site, and cold compresses or ice packs. Hetastarch, lactated Ringer's, or albumin will not control the bleeding related to hemophilia.
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A client is being treated in the hospital for hypovolemia related to a bleeding peptic ulcer. The nurse obtains a blood pressure reading of 88/62 mm Hg, heart rate of 112 beats/minute, and a respiratory rate of 24 breaths/minute. What is the first action by the nurse?
- A. Administer blood.
- B. Notify the physician.
- C. Insert two large-bore intravenous catheters.
- D. Administer a colloid solution.
Correct Answer: B
Rationale: A systolic blood pressure below 90 mm Hg and heart rate above 100 beats/minute should be reported immediately. Administering blood, inserting two large-bore IV catheters, and administration of a colloid solution should be performed only with a physician's prescription and may not be required at this time.
The nurse is admitting a client with Cooley's anemia to the hospital with a hemoglobin of 6.2 g/dL and hematocrit of 26%. What does the nurse document about the client's skin?
- A. Bronzing of the skin
- B. Jaundice of the skin and mucous membranes
- C. Ruddy complexion
- D. Pale skin and mucous membranes
Correct Answer: A
Rationale: Clients with Cooley's anemia, a severe form of beta-thalassemia, exhibit symptoms of severe anemia and a bronzing of the skin caused by hemolysis of erythrocytes. The client is not jaundiced, ruddy, or pale with this disorder.
The LPN is following a plan of care for a client who is being treated for hypovolemic anemia and is at risk for hypovolemic shock. The nurse assesses vital signs and O2 saturation and observes the saturation at 89% for 3 minutes. What should the first action by the nurse be?
- A. Notify the charge nurse.
- B. Prepare to assist with intubation.
- C. Give oxygen per nasal cannula
- D. Place the client in the supine position.
Correct Answer: C
Rationale: An expected outcome for the client with hypovolemic anemia is to monitor to detect hypoxemia and manage and minimize inadequate oxygenation. The oxygen saturation should be monitored to measure the percentage of oxygen bound to hemoglobin. The nurse should report a sustained oxygen saturation value below 90%. Give oxygen per nasal cannula or simple mask to maintain oxygen saturation at or above 90%. It is important to administer the oxygen first and then contact the charge nurse to alert them. It is not necessary at this time if the client is not in respiratory distress to intubate the client. Placing the client in the supine position would decrease the oxygen saturation level further.
The nurse reinforces education for a client who is diagnosed with a coagulopathy. Which client statement indicates a correct understanding of the definition for this disorder?
- A. My diagnosis means that I am missing or lacking components needed to control bleeding.
- B. My diagnosis is a bleeding disorder caused by a deficiency of globulins in my blood.
- C. My diagnosis is a bleeding disorder that involves red blood cells.
- D. My diagnosis means that I am at risk for developing blood clots.
Correct Answer: A
Rationale: The term coagulopathy refers to conditions in which a component that is necessary to control bleeding is missing or inadequate. Two common examples are thrombocytopenia and hemophilia. Coagulopathies do not involve red blood cells, nor are they characterized by a deficiency of globulins in the plasma.
The nurse is instructing the client with sickle cell disease about the use of an inhaled vasodilator that may reduce sickling. What medication is the nurse instructing the client about?
- A. Nitszyst oxide
- B. Nitric oxide
- C. Betamethasone
- D. Terbutaline
Correct Answer: B
Rationale: Inhaled nitric oxide-not nitrous oxide (laughing gas), a vasodilating agent- is believed to reduce sickling by promoting the binding of oxygen to hemoglobin. It is being used in the form of handheld inhalers to abort or relieve pain experienced during sickle cell crises. Betamethasone is a corticosteroid, and terbutaline is not used as an inhaler.