Nokea
At 1000 hours, the nurse is documenting the administration of 275 mL of compatible platelets, unit number XR123. Which information should the nurse document?
- A. One unit blood was administered over 4 hours.
- B. Platelet XR123 double-checked before infusion.
- C. No transfusion reactions noted during infusion.
- D. D5W infused with platelets to prevent clumping.
- E. Completed 275 mL of platelet infusion started at 0830.
Correct Answer: B, C, E,A.
Rationale: This documents an incomplete blood type, and platelets are unlikely to be administered over 4 hours. B. Documentation should include the type of product infused (platelets), product number (compatible platelets were ordered), and that it was double-checked. C. Documentation should include any adverse reactions. D. Only 0.9% NaCl should be used when administering blood or blood products, and usually only to purge the line before and after administration. E. Documentation should include volume infused. Platelets should be infused as fast as the client can tolerate the infusion to diminish clumping.
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The client is diagnosed with leukemia and has leukocytosis. Which laboratory value would the nurse expect to assess?
- A. An elevated hemoglobin.
- B. A decreased sedimentation rate.
- C. A decreased red cell distribution width.
- D. An elevated white blood cell count.
Correct Answer: D
Rationale: Leukocytosis in leukemia causes elevated WBCs (D). Hb (A) is low, ESR (B) is elevated, and RDW (C) is unrelated.
The nurse writes a client problem of 'activity intolerance' for a client diagnosed with anemia. Which intervention should the nurse implement?
- A. Pace activities according to tolerance.
- B. Provide supplements high in iron and vitamins.
- C. Administer packed red blood cells.
- D. Monitor vital signs every four (4) hours.
Correct Answer: A
Rationale: Pacing activities (A) conserves energy in anemia-related activity intolerance. Supplements (B) and transfusions (C) are medical, and vitals (D) are routine, not primary.
A child is being evaluated for possible leukemia. Which assessment finding is most likely to be present?
- A. Numerous bruises on the child's body
- B. Ruddy complexion
- C. Diarrhea and vomiting
- D. Chest pain
Correct Answer: A
Rationale: Numerous bruises are common in leukemia due to decreased platelets from bone marrow failure.
The nurse is planning the care of a client diagnosed with aplastic anemia. Which interventions should be taught to the client? Select all that apply.
- A. Avoid alcohol.
- B. Pace activities.
- C. Stop smoking.
- D. Eat a balanced diet.
- E. Use a safety razor.
Correct Answer: A,B,C,D
Rationale: Avoiding alcohol (A), pacing activities (B), stopping smoking (C), and balanced diet (D) support aplastic anemia management. Safety razors (E) risk bleeding due to thrombocytopenia.
An 8-year-old boy is admitted to the unit with a diagnosis of acute lymphocytic leukemia. During a routine physical exam, numerous ecchymotic areas were noted on his body. The parent reported that the child has been more tired than usual personally more tired than usual lately. The parent says that the child has had a cold for the last several weeks and asks if this is related to the leukemia. The nurse's response is based on the knowledge that:
- A. leukemia causes a decrease in the number of normal white blood cells in the body.
- B. a chronic infection such as the child has had makes a child more likely to develop leukemia.
- C. the virus responsible for colds is thought to cause leukemia.
- D. having an infection prior to the onset of leukemia is merely a coincidence.
Correct Answer: A
Rationale: Leukemia reduces normal white blood cells, impairing infection fighting, which may explain the prolonged cold. Infections do not cause leukemia.