Nokea
The client who received 50 mL from a unit of whole blood has low back pain. In response to this client’s symptom, which action should be taken by the nurse first?
- A. Reposition the client.
- B. Assess the pain further.
- C. Administer an analgesic.
- D. Stop the blood transfusion.
Correct Answer: D
Rationale: A. Repositioning focuses on treating the client’s back pain and not on the blood transfusion, which could be the cause of the back pain. B. Further assessment should occur after stopping the blood transfusion. C. The client may need an analgesic for pain control, but this should occur after stopping the blood transfusion. D. Low back pain is a symptom of a potentially life-threatening acute hemolytic reaction. The pain is caused from agglutination of RBCs in the kidneys and renal vasoconstriction. Hemolytic reactions occur most often within the first 50 mL of the infusion.
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The male client with sickle cell anemia comes to the emergency department with a temperature of 101.4°F and tells the nurse that he is having a sickle cell crisis. Which diagnostic test should the nurse anticipate the emergency department doctor ordering for the client?
- A. Spinal tap.
- B. Hemoglobin electrophoresis.
- C. Sickle-turbidity test (Sickledex).
- D. Blood cultures.
Correct Answer: D
Rationale: Fever (101.4°F) in SCA crisis suggests infection; blood cultures (D) identify the cause. Spinal tap (A) is for meningitis, electrophoresis (B) confirms SCA, and Sickledex (C) screens for sickle trait.
The client who is receiving doxorubicin for the first time to treat multiple myeloma develops flushing, facial swelling, headache, chills, and back pain. Which statement made by the nurse is best?
- A. “These symptoms usually resolve in 1 day and are limited to the first dose.”
- B. “These are signs of toxicity; you may want to consider refusing treatment.”
- C. “I can give you ondansetron prescribed prn now to alleviate these symptoms.”
- D. “Side effects occur with chemotherapy, but focus on your cancer being cured.”
Correct Answer: A
Rationale: A. This response is best. The nurse informs the client correctly that the symptoms of doxorubicin (Adriamycin) are limited to the first dose. B. The nurse is providing unsolicited advice. C. Ondansetron (Zofran) is an antiemetic and will not alleviate all of the symptoms. D. This response belittles the client’s symptoms. There is no cure for multiple myeloma. Treatment will control the illness and maintain the client’s level of functioning for several years or more.
The female client recently diagnosed with Hodgkin's lymphoma asks the nurse about her prognosis. Which is the nurse’s best response?
- A. Survival for Hodgkin’s disease is relatively good with standard therapy.
- B. Survival depends on becoming involved in an investigational therapy program.
- C. Survival is poor, with more than 50% of clients dying within six (6) months.
- D. Survival is fine for primary Hodgkin’s, but secondary cancers occur within a year.
Correct Answer: A
Rationale: Hodgkin’s has a good prognosis with standard therapy (A) (5-year survival >85%). Investigational therapy (B) isn’t required, survival isn’t poor (C), and secondary cancers (D) are long-term risks.
Fifteen minutes after the nurse has initiated a transfusion of packed red blood cells, the client becomes restless and complains of itching on the trunk and arms. Which intervention should the nurse implement first?
- A. Collect urine for analysis.
- B. Notify the laboratory of the reaction.
- C. Administer diphenhydramine, an antihistamine.
- D. Stop the transfusion at the hub.
Correct Answer: D
Rationale: Restlessness/itching suggest a transfusion reaction; stopping at the hub (D) prevents further reaction. Urine collection (A), notification (B), and Benadryl (C) follow.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients in a bone marrow transplantation unit. Which nursing task should the nurse delegate?
- A. Take the hourly vital signs on a client receiving blood transfusions.
- B. Monitor the infusion of antineoplastic medications.
- C. Transcribe the HCP’s orders onto the medication administration record (MAR).
- D. Determine the client’s response to the therapy.
Correct Answer: A
Rationale: Taking vital signs (A) is within UAP scope during transfusions. Monitoring chemo (B), transcribing orders (C), and evaluating response (D) require nursing judgment.