Nokea
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.
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Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia?
- A. Potential complication: seizures
- B. Potential complication: infection
- C. Potential complication: neurogenic shock
- D. Potential complication: pulmonary edema
Correct Answer: B
Rationale: The correct answer is B: Potential complication: infection. Patients with idiopathic aplastic anemia have pancytopenia, which puts them at a high risk for infections due to decreased production of all blood cells (red blood cells, white blood cells, and platelets). Infection is a significant concern in these patients. Choices A, C, and D are incorrect because seizures, neurogenic shock, and pulmonary edema are not typically associated with idiopathic aplastic anemia. While seizures can occur in some conditions that affect the brain, neurogenic shock is related to spinal cord injury, and pulmonary edema is more commonly seen in conditions like heart failure.
The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect?
- A. Yellow-tinged sclerae
- B. Shiny, smooth tongue
- C. Numbness of the extremities
- D. Gum bleeding and tenderness
Correct Answer: C
Rationale: The correct answer is C: Numbness of the extremities. Numbness of the extremities is a common finding in patients with pernicious anemia, which is caused by cobalamin (vitamin B12) deficiency. This deficiency affects the peripheral nervous system, leading to neurological symptoms like numbness and tingling in the extremities. Choices A, B, and D are incorrect: Yellow-tinged sclerae is more indicative of jaundice or liver dysfunction, a shiny smooth tongue is seen in conditions like glossitis, and gum bleeding and tenderness are associated with periodontal disease or vitamin C deficiency, not pernicious anemia.
A 62-year-old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory test findings to include
- A. an RBC count of 4,500,000/μL.
- B. a hematocrit (Hct) value of 38%.
- C. normal red blood cell (RBC) indices.
- D. a hemoglobin (Hgb) of 8.6 g/dL.
Correct Answer: B
Rationale: The correct answer is B. In chronic anemia, the hematocrit (Hct) value is a crucial indicator of the proportion of red blood cells in the blood. A hematocrit value of 38% indicates a lower than normal level of red blood cells, which aligns with the patient's symptoms of fatigue and palpitations. Choices A, C, and D are incorrect because a low RBC count, normal RBC indices, and a hemoglobin level of 8.6 g/dL do not specifically address the decreased red blood cell mass associated with chronic anemia.
A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to
- A. administer oxygen therapy at a high flow rate
- B. obtain a urine specimen to send to the laboratory
- C. notify the healthcare provider about the symptoms
- D. disconnect the transfusion and infuse normal saline
Correct Answer: D
Rationale: The patient's symptoms, back pain, and difficulty breathing after the transfusion indicate a possible acute hemolytic reaction, a severe transfusion reaction. The priority action in this situation is to discontinue the transfusion immediately to prevent further complications. Infusing normal saline helps maintain the patient's intravascular volume and prevent renal damage. Administering oxygen or obtaining a urine specimen is not the most urgent action and could delay essential treatment. Notifying the healthcare provider is important but should come after ensuring the patient's safety by stopping the blood transfusion.
After a patient with pancytopenia undergoes a bone marrow aspiration from the left posterior iliac crest, which action would be important for the nurse to take?
- A. Elevate the head of the bed to 45 degrees.
- B. Have the patient lie on the left side for 1 hour.
- C. Apply a sterile 2-inch gauze dressing to the site.
- D. Use a half-inch sterile gauze to pack the wound.
Correct Answer: B
Rationale: After a bone marrow aspiration, it is important to have the patient lie on the left side for 30 to 60 minutes to decrease the risk of bleeding. Elevating the head of the bed to 45 degrees does not directly address the risk of bleeding. Applying a sterile 2-inch gauze dressing to the site is important for wound care but does not specifically address post-procedural positioning. Using a half-inch sterile gauze to pack the wound is not necessary after a bone marrow aspiration.