Nokea
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical unit. Which task should the nurse delegate to the UAP?
- A. Check on the bowel movements of a client diagnosed with melena.
- B. Take the vital signs of a client who received blood the day before.
- C. Evaluate the dietary intake of a client who has been noncompliant with eating.
- D. Shave the client diagnosed with severe hemolytic anemia.
Correct Answer: B
Rationale: Taking vital signs post-transfusion (B) is within UAP scope. Checking melena (A), evaluating diet (C), and shaving with anemia (D) require nursing judgment due to bleeding risks.
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The client’s laboratory values are RBCs 5.5 (x106/mm3), WBCs 8.9 (x103/mm3), and platelets 189 (x103/mm3). Which intervention should the nurse implement?
- A. Prepare to administer packed red blood cells.
- B. Continue to monitor the client.
- C. Request an order for Neupogen, a biologic response modifier.
- D. Institute bleeding precautions.
Correct Answer: B
Rationale: Labs are normal (RBC 5.5, WBC 8.9, platelets 189); continue monitoring (B). Transfusions (A), Neupogen (C), and bleeding precautions (D) are unnecessary.
The client diagnosed with end-stage renal disease (ESRD) has developed anemia. Which would the nurse anticipate the HCP prescribing for this client?
- A. Place the client in reverse isolation.
- B. Discontinue treatments until blood count improves.
- C. Monitor CBC daily to assess for bleeding.
- D. Give client erythropoietin, a biologic response modifier.
Correct Answer: D
Rationale: ESRD causes erythropoietin deficiency; prescribing erythropoietin (D) treats anemia. Isolation (A), stopping treatment (B), and daily CBC (C) are inappropriate.
The nurse is caring for the following clients. Which client should the nurse assess first?
- A. The client whose partial thromboplastin time (PTT) is 38 seconds.
- B. The client whose hemoglobin is 14 g/dL and hematocrit is 45%.
- C. The client whose platelet count is 75,000 per cubic millimeter of blood.
- D. The client whose red blood cell count is 4.8 x 106/mm3.
Correct Answer: C
Rationale: Platelets 75,000 (C) indicate thrombocytopenia, risking bleeding, a priority. PTT 38 (A) is therapeutic, Hb/Hct (B) are normal, and RBC 4.8 (D) is normal.
The nurse is completing a care plan for a client diagnosed with leukemia. Which independent problem should be addressed?
- A. Infection.
- B. Anemia.
- C. Nutrition.
- D. Grieving.
Correct Answer: A
Rationale: Infection (A) is critical in leukemia due to neutropenia, requiring independent nursing actions (e.g., hygiene). Anemia (B), nutrition (C), and grieving (D) are collaborative or secondary.
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.