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An older adult patient is receiving a transfusion of packed red blood cells after being injured in a car accident. On assessment, the nurse notes a new finding of bounding pulse, crackles, and increasing dyspnea. What should the nurse do first, after stopping the transfusion?
- A. Assess vital signs.
- B. Raise the head of the bed.
- C. Encourage the patient to deep breathe and cough.
- D. Administer pm diphenhydramine (Benadryl) as ordered.
Correct Answer: B
Rationale: The correct answer is B: Raise the head of the bed. This action is crucial in managing the potential complication of fluid overload in the patient receiving a blood transfusion. Elevating the head of the bed helps reduce venous return to the heart, decreasing preload and cardiac workload. This can alleviate symptoms like dyspnea and crackles associated with fluid overload. Assessing vital signs (choice A) is important but should follow positioning the patient appropriately. Encouraging deep breathing and coughing (choice C) may exacerbate the patient's respiratory distress. Administering diphenhydramine (choice D) is not indicated for the symptoms described.
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Macrocytosis is a characteristic of all except:
- A. an. Of myxedema
- B. methotrexate induced
- C. chronic alcoholism induced liver dis.
- D. SLE
Correct Answer: D
Rationale: Step-by-step rationale:
1. Macrocytosis refers to larger-than-normal red blood cells.
2. Systemic Lupus Erythematosus (SLE) is not typically associated with macrocytosis.
3. Anemia of myxedema, methotrexate-induced, and chronic alcoholism-induced liver disease can all lead to macrocytosis.
4. Therefore, the correct answer is D: SLE, as it is not commonly associated with macrocytosis.
A nurse is caring for four clients. After reviewing today's laboratory results, which client would the nurse assess first?
- A. Client with an international normalized ratio of 2.8
- B. Client with a platelet count of 128,000/mm3 (128 x 109/L).
- C. Client with a prothrombin time (PT) of 28 seconds
- D. Client with a red blood cell count of 5.1 million/mcl. (5.1 x 1012/L)
Correct Answer: C
Rationale: The correct answer is C because a prothrombin time (PT) of 28 seconds indicates potential issues with blood clotting and can be a sign of bleeding disorders or liver dysfunction, requiring immediate assessment and intervention to prevent complications.
Choice A (INR of 2.8) is within the therapeutic range for clients on anticoagulant therapy, so it's not an immediate concern. Choice B (platelet count of 128,000/mm3) is low but not critically low, so it doesn't require immediate assessment. Choice D (red blood cell count of 5.1 million/mcl) is within the normal range and doesn't indicate urgent issues.
In summary, the nurse should assess the client with a PT of 28 seconds first due to the potential risk of bleeding or clotting disorders, while the other choices are not as urgent.
A 13-year-old Hispanic girl is found to have a WBC count of 6,500/mm3 with 40% Auer rod–containing granular blasts that, by flow cytometry, express very bright CD33 but are negative for human leukocyte antigen–DR isotype (HLA-DR). She is oozing blood around her peripheral IV site. Coagulation studies reveal an international normalized ratio (INR) of 3.4, a fibrinogen of 170, and a markedly elevated D-dimer. Marrow aspirate shows nearly 90% blasts with a similar morphology. You send the marrow to the fluorescence in situ hybridization (FISH) lab and request STAT testing for the most likely recurrent genetic abnormality based on the clinical presentation. How do you plan to initiate therapy?
- A. Perform a lumbar puncture to determine leukemic involvement, then proceed with induction chemotherapy.
- B. Begin therapy with all-trans retinoic acid (ATRA) immediately while aggressively managing coagulopathy with blood product support.
- C. Start dexamethasone and hydroxyurea immediately while aggressively managing coagulopathy with blood product support.
- D. Start induction chemotherapy, obtain HLA typing, and start a donor search because of the poor prognosis associated with this leukemic phenotype.
Correct Answer: B
Rationale: The correct answer is B: Begin therapy with all-trans retinoic acid (ATRA) immediately while aggressively managing coagulopathy with blood product support. In this scenario, the patient presents with acute promyelocytic leukemia (APL), characterized by the presence of Auer rod-containing blasts expressing CD33 and negative for HLA-DR. The presence of coagulopathy with elevated INR, D-dimer, and oozing blood suggests disseminated intravascular coagulation (DIC), a common complication in APL. Immediate treatment with ATRA is crucial to differentiate and mitigate the risk of DIC worsening. ATRA induces differentiation of APL blasts, resolving the coagulopathy. Aggressive management of coagulopathy with blood product support is essential to prevent bleeding complications. Lumbar puncture (choice A), dexamethasone and hydroxyurea (choice C), and starting a donor search (choice D) are not indicated as the
A 14-year-old Syrian male with beta thalassemia major has relocated to your community as a refugee. He has been receiving chronic transfusion therapy in Turkey for the past 3 years. On his first visit, you notice that his height is below the fifth percentile. He has skin discoloration and hepatosplenomegaly. His mother reports they have not had regular access to chelation therapy. Laboratory testing shows a serum ferritin of 6,200 ng/mL. A cardiac MRI shows grossly normal cardiac function but a T2* value of 9 ms. What is the most likely cause of his short stature?
- A. Lack of regular blood transfusion causing growth failure
- B. Cirrhosis and liver failure
- C. Ineffective erythropoiesis and chronic anemia
- D. Growth hormone deficiency due to iron deposition in the pituitary
Correct Answer: D
Rationale: The correct answer is D: Growth hormone deficiency due to iron deposition in the pituitary. Iron overload in patients with beta thalassemia major can lead to iron deposition in various organs, including the pituitary gland, impairing its function. This can result in growth hormone deficiency, leading to short stature. In this case, the patient's history of chronic transfusions and high serum ferritin level indicate iron overload, which can affect the pituitary gland. Choices A, B, and C are incorrect because growth failure in beta thalassemia major is primarily attributed to endocrine complications such as growth hormone deficiency, rather than lack of transfusions, cirrhosis, or ineffective erythropoiesis.
A 15-year-old female presents with 1 month of fatigue and 3 days of chest pain and shortness of breath. Her physical exam is unremarkable. A chest x-ray shows a large mediastinal mass that is greater than 33% of the diameter of her chest cavity. A biopsy shows nodular sclerosing, classic Hodgkin lymphoma (cHL). Metastatic workup at diagnosis, including CT scan of neck, chest, abdomen, and pelvis and PET scan, shows no other site of disease. According to the Ann Arbor staging system, the patient has which stage of cHL?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
Correct Answer: A
Rationale: The correct answer is A: Stage I. In the Ann Arbor staging system for Hodgkin lymphoma, Stage I indicates involvement of a single lymph node region or a single extralymphatic organ or site. In this case, the patient's disease is limited to the mediastinum without involvement of other lymph nodes or organs. The large mediastinal mass is considered as a single site of disease. The absence of disease involvement in other areas based on the metastatic workup supports the classification as Stage I. The other choices (B, C, D) are incorrect because they represent more extensive disease involving multiple lymph node regions or extralymphatic organs, which is not the case in this patient.