Nokea
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.
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The unlicensed assistive personnel (UAP) asks the primary nurse, 'How does someone get hemophilia A?' Which statement would be the primary nurse’s best response?
- A. It is an inherited X-linked recessive disorder.'
- B. There is a deficiency of the clotting factor VIII.'
- C. The person is born with hemophilia A.'
- D. The mother carries the gene and gives it to the son.'
Correct Answer: A
Rationale: Hemophilia A is an X-linked recessive disorder (A), the most precise explanation. Factor VIII deficiency (B) is a result, born with it (C) is vague, and mother-to-son (D) is partial.
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.
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 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.
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
Rationale: A, C: A. Adequate hydration dilutes calcium and prevents precipitates from causing renal tubular obstruction. B. The client with multiple myeloma is encouraged to ambulate because weight-bearing activities can help the bone resorb some calcium as well as prevent thrombosis that can accompany immobility. C. Furosemide (Lasix) given IV can promote the excretion of calcium when hypercalcemia exists due to multiple myeloma. D. Allopurinol (Zyloprim) may be administered to reduce the hyperuricemia that can accompany multiple myeloma, not the hypercalcemia. E. The serum calcium level is elevated (normal is 9–10.5 mg/dL). Foods high in calcium would not be offered. However, limiting the intake of foods high in calcium will not make any difference to the elevated calcium level that is caused by cancer.