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The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take?
- A. Notify the patients physician.
- B. Stop the transfusion immediately.
- C. Remove the patients IV access.
- D. Assess the patients chest sounds and vital signs.
Correct Answer: B
Rationale: Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions. The nurse should discontinue the transfusion immediately, monitor the patients vital signs, and notify the physician. The blood container and tubing should be sent to the blood bank. A blood and urine specimen may be needed if a transfusion reaction or a bacterial infection is suspected. The patients IV access should not be removed.
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A patients electronic health record states that the patient receives regular transfusions of factor IX. The nurse would be justified in suspecting that this patient has what diagnosis?
- A. Leukemia
- B. Hemophilia
- C. Hypoproliferative anemia
- D. Hodgkins lymphoma
Correct Answer: B
Rationale: Administration of clotting factors is used to treat diseases where these factors are absent or insufficient; hemophilia is among the most common of these diseases. Factor IX is not used in the treatment of leukemia, lymphoma, or anemia.
A patient undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions?
- A. Safe transfusion for patients with a history of transfusion reactions
- B. Prevention of viral infections from another persons blood
- C. Avoidance of complications in patients with alloantibodies
- D. Prevention of alloimmunization
Correct Answer: B
Rationale: The primary advantage of autologous transfusions is the prevention of viral infections from another persons blood. Other secondary advantages include safe transfusion for patients with a history of transfusion reactions, prevention of alloimmunization, and avoidance of complications in patients with alloantibodies.
The nurse educating a patient with anemia is describing the process of RBC production. When the patients kidneys sense a low level of oxygen in circulating blood, what physiologic response is initiated?
- A. Increased stem cell synthesis
- B. Decreased respiratory rate
- C. Arterial vasoconstriction
- D. Increased production of erythropoietin
Correct Answer: D
Rationale: If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (i.e., anemia), erythropoietin levels increase. The body does not compensate with vasoconstriction, decreased respiration, or increased stem cell activity.
A patient has been diagnosed with a lymphoid stem cell defect. This patient has the potential for a problem involving which of the following?
- A. Plasma cells
- B. Neutrophils
- C. Red blood cells
- D. Platelets
Correct Answer: A
Rationale: A defect in a myeloid stem cell can cause problems with erythrocyte, leukocyte, and platelet production. In contrast, a defect in the lymphoid stem cell can cause problems with T or B lymphocytes, plasma cells (a more differentiated form of B lymphocyte), or natural killer (NK) cells.
A patients diagnosis of atrial fibrillation has prompted the primary care provider to prescribe warfarin (Coumadin), an anticoagulant. When assessing the therapeutic response to this medication, what is the nurses most appropriate action?
- A. Assess for signs of myelosuppression.
- B. Review the patients platelet level.
- C. Assess the patients capillary refill time.
- D. Review the patients international normalized ratio (INR).
Correct Answer: D
Rationale: The INR and aPTT serve as useful screening tools for evaluating a patients clotting ability and to monitor the therapeutic effectiveness of anticoagulant medications. The patients platelet level is not normally used as a short-term indicator of anticoagulation effectiveness. Assessing the patient for signs of myelosuppression and capillary refill time does not address the effectiveness of anticoagulants.