Nokea
The client diagnosed with thalassemia, a hereditary anemia, is to receive a transfusion of packed RBCs. The crossmatch reveals the presence of antibodies that cannot be crossmatched. Which precaution should the nurse implement when initiating the transfusion?
- A. Start the transfusion at 10 to 15 mL/hr for 15 to 30 minutes.
- B. Re-crossmatch the blood until the antibodies are identified.
- C. Have the client sign a permit to receive uncrossmatched blood.
- D. Have the unlicensed assistive personnel stay with the client.
Correct Answer: A
Rationale: Uncrossmatched blood requires slow infusion (10–15 mL/hr) initially (A) to monitor reactions. Re-crossmatching (B) is impractical, consent (C) is for emergencies, and UAP (D) cannot monitor.
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The nurse has been teaching the parents of a child with hemophilia about the care he will need. Which statement by the parents indicates a need for more instruction?
- A. If my child needs something for pain or a fever, I will give him acetaminophen instead of aspirin.'
- B. I will take my child to the dentist for regular checkups.'
- C. I will keep my child in the house most of the time.'
- D. My son's Medic Alert Bracelet arrived.'
Correct Answer: C
Rationale: Overprotecting the child by keeping him indoors most of the time prevents normal development. Acetaminophen, dental care, and a Medic Alert bracelet are appropriate.
A coworker being oriented by another nurse states, “I’m confused; a physician told me that graft-versus-host disease (GVHD) symptoms were desirable for a particular client after a bone marrow transplant.” Which should be the nurse’s best response?
- A. “GVHD isn’t desirable. Maybe you heard the physician wrong.”
- B. “That’s interesting. Did the client have a gastrointestinal tumor?”
- C. “That’s right if the transplant involved using autologous stem cells.”
- D. “GVHD is sometimes desirable with a hematological malignancy.”
Correct Answer: D
Rationale: A. GVHD is desirable if the primary source is hematological. B. Bone marrow transplant is not a treatment for GI malignancies unless the primary source is hematological. C. GVHD does not occur when a person receives autologous (his or her own) cells during a transplant. D. GVHD is sometimes desirable with a hematological malignancy. The donor lymphocytes can mount a reaction against any lingering tumor cells and destroy them.
Which concepts could the nurse identify for a client diagnosed with lymphoma? Select all that apply.
- A. Coping.
- B. Hematologic regulation.
- C. Tissue perfusion.
- D. Clotting.
- E. Clinical judgment.
Correct Answer: A,B,C,D
Rationale: Lymphoma involves coping (A) with diagnosis, hematologic regulation (B) via lymph dysfunction, perfusion (C) due to node obstruction, and clotting (D) from thrombocytopenia. Clinical judgment (E) is a nursing process, not a patient concept.
The client, who underwent a right mastectomy with lymph node dissection, is being admitted to a nursing unit from the PACU. When settling the client in bed, which action by the NA requires the nurse to intervene?
- A. Placing a blood pressure cuff on the left arm for vital signs
- B. Taping a sign to the side rail stating no IV or lab draws on the right
- C. Elevating the bed to 90 degrees and keeping the right arm dependent
- D. Asking if the client feels ready to allow family to enter the room
Correct Answer: C
Rationale: A. BPs, venipunctures, and injections should not be done on the affected arm, so taking the BP on the left arm would be appropriate. B. It would be appropriate for the NA to tape a sign at the side rail to remind others of the restrictions following a mastectomy. C. The client should be placed in a semi-Fowler’s position with the arm on the affected side elevated on a pillow to promote restoring arm function and to prevent arm edema. D. It would be beneficial for the NA and nurse to be sensitive to the client’s readiness for family presence.
The client diagnosed with anemia begins to complain of dyspnea when ambulating in the hall. Which intervention should the nurse implement first?
- A. Apply oxygen via nasal cannula.
- B. Get a wheelchair for the client.
- C. Assess the client’s lung fields.
- D. Assist the client when ambulating in the hall.
Correct Answer: B
Rationale: Dyspnea in anemia suggests low oxygen-carrying capacity; a wheelchair (B) prevents exertion while further assessment occurs. Oxygen (A), lung assessment (C), and assistance (D) follow.