Nokea
The client received two (2) units of packed red blood cells of 250 mL with 63 mL of preservative each during the shift. There was 240 mL of saline remaining in the 500-mL bag when the nurse discarded the blood tubing. How many milliliters of fluid should be documented on the intake and output record?
Correct Answer: 886
Rationale: Each unit = 250 mL RBC + 63 mL preservative = 313 mL. Two units = 313 × 2 = 626 mL. Saline used = 500 – 240 = 260 mL. Total intake = 626 + 260 = 886 mL.
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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 nurse writes a client problem of 'activity intolerance' for a client diagnosed with anemia. Which intervention should the nurse implement?
- A. Pace activities according to tolerance.
- B. Provide supplements high in iron and vitamins.
- C. Administer packed red blood cells.
- D. Monitor vital signs every four (4) hours.
Correct Answer: A
Rationale: Pacing activities (A) conserves energy in anemia-related activity intolerance. Supplements (B) and transfusions (C) are medical, and vitals (D) are routine, not primary.
The nurse has identified the concept of cellular deviation for a client diagnosed with chronic myelogenous leukemia. Which intervention should the nurse implement? Select all that apply.
- A. Screen visitors for infection before allowing them to enter the room.
- B. Assess the client’s vital signs every four (4) hours.
- C. Do not allow fresh fruits and vegetables on diet trays.
- D. Monitor the client’s white blood cell count.
- E. Place the client on droplet isolation.
- F. Check the client’s bone marrow results daily.
Correct Answer: A,C,D
Rationale: Screening visitors (A), avoiding fresh produce (C), and monitoring WBCs (D) reduce infection risk in CML. Vitals (B) are routine, droplet isolation (E) is excessive, and daily bone marrow (F) is impractical.
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
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When reviewing the morning serum laboratory results of the client with multiple myeloma, the nurse sees that the total calcium level is 13.2 mEq/L. Which interventions, if prescribed by the HCP, should the nurse plan to implement?
- A. Encourage fluid intake.
- B. Maintain strict bedrest.
- C. Administer furosemide IV.
- D. Give allopurinol by mouth.
- E. Offer foods high in calcium.
Correct Answer: C
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