Nokea
The client receiving a unit of PRBCs begins to chill and develops hives. Which action should be the nurse’s first response?
- A. Notify the laboratory and health-care provider.
- B. Administer the histamine-1 blocker, Benadryl, IV.
- C. Assess the client for further complications.
- D. Stop the transfusion and change the tubing at the hub.
Correct Answer: D
Rationale: Chills/hives suggest a transfusion reaction; stopping the transfusion at the hub (D) prevents further reaction. Assessment (C), Benadryl (B), and notification (A) follow.
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The nurse receives orders after notifying an HCP about the client who has tachycardia, diaphoresis, and an elevated temperature after treatments for ALL. Which order should be the nurse’s priority?
- A. Portable chest x-ray in the client’s room
- B. Urine culture, and blood cultures x 2
- C. Vancomycin 500 mg IV q6h
- D. Filgrastim 0.3 mg subcut daily
Correct Answer: B
Rationale: A. The results of the portable CXR will help determine if the cause is a respiratory infection. It will not change the treatment. B. Urine and blood cultures are priority; these should be obtained before antibiotics are administered. C. National recommendations are to administer broad-spectrum antibiotics such as vancomycin (Vancocin) within 1 hour of a suspected infection diagnosis. The antibiotics may be changed after culture and sensitivity reports are available (usually 24 to 48 hours). D. It takes 4 days for filgrastim (Neupogen) to return the neutrophil count to baseline, so this is not priority. Filgrastim should not be given within 24 hours of cytotoxic chemotherapy.
The nurse is teaching the client who is a strict vegetarian how to decrease the risk of developing megaloblastic anemia. Which information should the nurse provide?
- A. Undergo an annual Schilling test.
- B. Increase intake of foods high in iron.
- C. Supplement the diet with vitamin B12.
- D. Have a hemoglobin level drawn monthly.
Correct Answer: C
Rationale: A. The Schilling test is used to diagnose vitamin B12 deficiency; it is not necessary to have this completed annually. B. Consuming foods high in iron will prevent iron-deficiency, not megaloblastic, anemia. C. The client consuming a vegetarian diet can prevent megaloblastic anemia from a vitamin B12 deficiency with oral vitamin supplements or fortified soy milk. D. Monthly lab work is unnecessary and costly.
The nurse is working in a blood bank facility procuring units of blood from donors. Which client would not be a candidate to donate blood?
- A. The client who had wisdom teeth removed a week ago.
- B. The nursing student who received a measles immunization two (2) months ago.
- C. The mother with a six (6)-week-old newborn.
- D. The client who developed an allergy to aspirin in childhood.
Correct Answer: C
Rationale: Recent childbirth (C) (within 6 months) disqualifies blood donation due to anemia risk. Wisdom teeth (A), immunization (B), and aspirin allergy (D) are not contraindications.
The nurse is preparing to administer epoetin alfa to the client who has chemotherapy-associated anemia. The nurse recognizes the need to consult with the HCP before administration when the client makes which statements?
- A. “I spend most of my days lying on the couch.”
- B. “I usually eat a lot of salads for my main meals.”
- C. “I seem to have an aversion to eating eggs right now.”
- D. “I developed a blood clot in my leg on my last admission.”
- E. “I hope this helps so I don’t have to have a blood transfusion.”
Correct Answer: A, D
Rationale: Erythropoiesis-stimulating agents, such as epoetin alfa (Epogen), can cause thromboembolic events. It would be concerning if the client had limited activity because this could further increase the client’s risk of a thromboembolic event. B. Dark green, leafy vegetables are high in iron and help with Hgb synthesis and therefore would be beneficial. C. Eggs are high in iron, but there are other food sources high in iron that the client can consume if an aversion exists. D. A history of a thromboembolic event and use of epoetin alfa increase the client’s risk for another thromboembolic event. E. The use of epoetin alfa is recommended as a treatment option for clients with chemotherapy-associated anemia and an Hgb concentration that is approaching, or has fallen below, 10 g/dL, to increase the Hgb level and decrease the need for a transfusion.
The client who has renal cancer that has metastasized rates pain at a 9 on a 0 to 10 pain scale. Which medication should the nurse plan to administer now and then schedule to be administered at the prescribed dosing interval?
- A. Meperidine
- B. Propoxyphene
- C. Pentazocine
- D. Oxycodone
Correct Answer: D
Rationale: A. Meperidine (Demerol) is not recommended because it causes CNS toxicity from metabolites. It should not be used for the treatment of chronic pain. B. Propoxyphene