Nokea
The client is diagnosed with congestive heart failure and anemia. The HCP ordered a transfusion of two (2) units of packed red blood cells. The unit has 250 mL of red blood cells plus 45 mL of additive. At what rate should the nurse set the IV pump to infuse each unit of packed red blood cells?
Correct Answer: 74
Rationale: Each unit = 250 mL RBC + 45 mL additive = 295 mL. Standard transfusion time is 4 hours max. 295 mL ÷ 4 hr = 73.75 mL/hr, rounded to 74 mL/hr for pump precision.
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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.
Which of the following assessment findings should alert the nurse that the elderly client should be evaluated for pernicious anemia?
- A. Clubbing of the nails
- B. Bloody stools
- C. Beefy-red tongue
- D. Enlarged lymph nodes
Correct Answer: C
Rationale: A beefy-red tongue is a classic symptom of pernicious anemia due to vitamin B12 deficiency.
The nurse writes the problem of 'grieving' for a client diagnosed with non-Hodgkin's lymphoma. Which collaborative intervention should be included in the plan of care?
- A. Encourage the client to talk about feelings of loss.
- B. Arrange for the family to plan a memorable outing.
- C. Refer the client to the American Cancer Society’s Dialogue group.
- D. Have the chaplain visit with the client.
Correct Answer: C
Rationale: Grieving requires collaborative support; ACS Dialogue group (C) provides peer support. Talking (A) is independent, outings (B) are nonspecific, and chaplain visits (D) are spiritual, not primary.
The client had basal cell carcinoma (BCC) lesions excised the day before at an outpatient clinic. The client telephones the nurse expressing concerns that the wounds are draining watery, pale pink fluid and that the small dressing is leaking. Which action should the nurse recommend?
- A. Apply ice to the area
- B. Contact the surgeon
- C. Take pain medication
- D. Change the dressings
Correct Answer: D
Rationale: A. Applying ice to the area is not necessary because the client did not mention swelling. B. Since the wounds do not drain purulent material, contacting the physician is not necessary. C. Because the client is not experiencing pain, pain medication is not needed. D. The nurse should recommend changing the dressing because a small amount of serosanguineous drainage is a normal response to surgical removal of a lesion.
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.