Nokea
Fifteen minutes after the nurse has initiated a transfusion of packed red blood cells, the client becomes restless and complains of itching on the trunk and arms. Which intervention should the nurse implement first?
- A. Collect urine for analysis.
- B. Notify the laboratory of the reaction.
- C. Administer diphenhydramine, an antihistamine.
- D. Stop the transfusion at the hub.
Correct Answer: D
Rationale: Restlessness/itching suggest a transfusion reaction; stopping at the hub (D) prevents further reaction. Urine collection (A), notification (B), and Benadryl (C) follow.
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The 24-year-old female client is diagnosed with idiopathic thrombocytopenic purpura (ITP). Which question would be important for the nurse to ask during the admission interview?
- A. Do you become short of breath during activity?'
- B. How heavy are your menstrual periods?'
- C. Do you have a history of deep vein thrombosis?'
- D. How often do you have migraine headaches?'
Correct Answer: B
Rationale: ITP causes bleeding; heavy menstrual periods (B) assess bleeding severity. Dyspnea (A), DVT (C), and migraines (D) are unrelated.
The nurse is discussing the prevention of bladder cancer with the client. Which factors that increase the client’s risk for bladder cancer should the nurse emphasize?
- A. Consuming caffeine beverages
- B. Smoking tobacco products
- C. Consuming multivitamins daily
- D. Prolonged exposure to paint smells
- E. Prolonged exposure to rubber smells
Correct Answer: B, D, E, A
Rationale: Consumption of caffeine is not associated with an increased risk for bladder cancer. B. Smoking is the number one cause of bladder cancer in the world. C. Studies show a protective effect with an increased intake of vitamins A, B6, and E. D. Exposure to aromatic amines in the textile and paint industries is clearly associated with bladder cancer. E. Exposure to aromatic amines in the rubber industry is clearly associated with bladder cancer.
Which collaborative treatment would the nurse anticipate for the client diagnosed with DIC?
- A. Administer oral anticoagulants.
- B. Prepare for plasmapheresis.
- C. Administer frozen plasma.
- D. Calculate the intake and output.
Correct Answer: C
Rationale: Frozen plasma (C) replaces clotting factors in DIC. Oral anticoagulants (A) worsen bleeding, plasmapheresis (B) is rare, and I&O (D) is routine.
The nurse is caring for the following clients. Which client should the nurse assess first?
- A. The client whose partial thromboplastin time (PTT) is 38 seconds.
- B. The client whose hemoglobin is 14 g/dL and hematocrit is 45%.
- C. The client whose platelet count is 75,000 per cubic millimeter of blood.
- D. The client whose red blood cell count is 4.8 x 106/mm3.
Correct Answer: C
Rationale: Platelets 75,000 (C) indicate thrombocytopenia, risking bleeding, a priority. PTT 38 (A) is therapeutic, Hb/Hct (B) are normal, and RBC 4.8 (D) is normal.
The nurse is completing a care plan for a client diagnosed with leukemia. Which independent problem should be addressed?
- A. Infection.
- B. Anemia.
- C. Nutrition.
- D. Grieving.
Correct Answer: A
Rationale: Infection (A) is critical in leukemia due to neutropenia, requiring independent nursing actions (e.g., hygiene). Anemia (B), nutrition (C), and grieving (D) are collaborative or secondary.