Nokea
The client diagnosed with sickle cell disease is experiencing a vaso-occlusive crisis. Which priority interventions should the nurse implement?
- A. Maintain IV fluids and administer pain medication prn.
- B. Encourage frequent ambulation in the hallways.
- C. Administer oxygen via nasal cannula at 10 LPM.
- D. Monitor the client’s red blood cell count every four (4) hours.
Correct Answer: A
Rationale: IV fluids and pain medication (A) prevent sickling and manage vaso-occlusive crisis pain. Ambulation (B) risks hypoxia, 10 LPM oxygen (C) is excessive, and RBC monitoring (D) is not primary.
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Which nursing interventions should the nurse implement when caring for a client diagnosed with hemophilia A? Select all that apply.
- A. Instruct the client to use a razor blade to shave.
- B. Avoid administering enemas to the client.
- C. Encourage participation in noncontact sports.
- D. Teach the client how to apply direct pressure if bleeding occurs.
- E. Explain the importance of not flossing the gums.
Correct Answer: B,C,D
Rationale: Avoiding enemas (B), noncontact sports (C), and teaching pressure (D) prevent bleeding in hemophilia. Razor blades (A) and avoiding flossing (E) increase bleeding risk.
The nurse is caring for the client experiencing superior vena cava syndrome secondary to lung cancer. Which problem should be the nurse’s priority?
- A. Ineffective breathing pattern
- B. Ineffective tissue perfusion
- C. Risk for infection
- D. Impaired skin integrity
Correct Answer: A
Rationale: A. Ineffective breathing pattern occurs with superior vena cava syndrome because the superior vena cava is located next to the main stem bronchus and causes compression of the intrathoracic structures. B. Ineffective tissue perfusion may occur with superior vena cava syndrome, but ineffective breathing pattern is priority. C. Risk for infection occurs with chemotherapy treatment and not from superior vena cava syndrome. D. Impaired skin integrity occurs with malignant skin conditions and usually not from lung cancer.
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.
The unlicensed assistive personnel (UAP) asks the primary nurse, 'How does someone get hemophilia A?' Which statement would be the primary nurse’s best response?
- A. It is an inherited X-linked recessive disorder.'
- B. There is a deficiency of the clotting factor VIII.'
- C. The person is born with hemophilia A.'
- D. The mother carries the gene and gives it to the son.'
Correct Answer: A
Rationale: Hemophilia A is an X-linked recessive disorder (A), the most precise explanation. Factor VIII deficiency (B) is a result, born with it (C) is vague, and mother-to-son (D) is partial.
The nurse teaches a coworker about the treatment for hemophilia. The nurse instructs that the treatment will likely include periodic self-administration of which component?
- A. Platelets
- B. Whole blood
- C. Factor concentrates
- D. Fresh frozen plasma
Correct Answer: C
Rationale: A. Platelets do not contain the deficient clotting factors. B. Although whole blood contains the deficient factors, periodic administration of factor concentrates are safer. C. A person with hemophilia A is deficient in factor VIII; hemophilia B, factor IX; and von Willebrand’s hemophilia, the von Willebrand’s factor and factor VIII. Recombinant forms of the factors are available for the client to self-administer intravenously at home. D. Although fresh frozen plasma contains the deficient factors, periodic administration of factor concentrates are safer.