Nokea
The client is hospitalized with a diagnosis of sickle cell crisis. Which findings should prompt the nurse to consider that the client is ready for discharge?
- A. Leukocyte count is at 7500/mm3
- B. Describes the importance of keeping warm
- C. Pain controlled at 2 on a 0 to 10 scale with analgesics
- D. Has not had chest pain or dyspnea for past 24 hours
- E. Blood transfusions effective in diminishing cell Sickling
- F. Hydroxyurea effective in suppressing leukocyte formation
Correct Answer: A, B, C, D
Rationale: leukocyte count of 7500/mm3 is within normal range (5000 to 10,000/mm3 indicates the absence of an infection). B. Keeping warm and avoiding chills will help to prevent infection. Cold causes vasoconstriction, slowing blood flow and aggravating the Sickling process. C. Acute pain is due to tissue hypoxia from the agglutination of sickled cells within blood vessels. D. The absence of symptoms of complication such as acute chest syndrome and pulmonary hypertension indicates readiness for discharge. E. RBC transfusions may help to prevent complications, but transfusions do not alter the person’s body from producing the deformed erythrocytes. F. Hydroxyurea (Hydrea) can decrease the permanent formation of sickled cells. A side effect (not therapeutic effect) of hydroxyurea is suppression of leukocyte formation.
You may also like to solve these questions
The client receiving hospice care has cancer pain and requires treatment with a co-analgesic for pain control. Which medication should the nurse request an HCP to prescribe because it gives the best pain-relieving response when given with opioids?
- A. Promethazine
- B. Gabapentin
- C. Diphenhydramine
- D. Droperidol
Correct Answer: B
Rationale: Promethazine (Phenergan) is given with pain medications, but it treats nausea and vomiting, not pain. Gabapentin (Neurontin) is often administered with opioid pain medications because of its efficacy in relieving neuropathic pain and its limited adverse effects. Diphenhydramine (Benadryl) is not a co-analgesic but an antihistamine. Droperidol (Inapsine) is not a co-analgesic but an antiemetic to control nausea and vomiting.
The client undergoing knee replacement surgery has a 'cell saver' apparatus attached to the knee when he arrives in the post-anesthesia care unit (PACU). Which intervention should the nurse implement to care for this drainage system?
- A. Infuse the drainage into the client when a prescribed amount fills the chamber.
- B. Attach an hourly drainage collection bag to the unit and discard the drainage.
- C. Replace the unit with a continuous passive motion (CPM) unit and start it on low.
- D. Have another nurse verify the unit number prior to reinfusing the blood.
Correct Answer: A
Rationale: Cell saver reinfuses collected blood (A) per protocol to reduce allogeneic transfusion. Discarding (B) wastes blood, CPM (C) is unrelated, and verification (D) is for donor blood.
The client diagnosed with anemia is admitted to the emergency department with dyspnea, cool pale skin, and diaphoresis. Which assessment data warrant immediate intervention?
- A. The vital signs are T 98.6°F, P 116, R 28, and BP 88/62.
- B. The client is allergic to multiple antibiotic medications.
- C. The client has a history of receiving chemotherapy.
- D. ABGs are pH 7.35, Pco2 44, Hco3 22, Pao2 92.
Correct Answer: A
Rationale: Tachycardia, tachypnea, and hypotension (A) indicate severe anemia with hypoxia, requiring immediate action. Allergies (B), chemo history (C), and normal ABGs (D) are secondary.
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.
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.