Nokea
The nurse is admitting a patient with hemolytic anemia and notes jaundice of the sclerae. Which of the following laboratory results should the nurse assess?
- A. Schilling test
- B. Bilirubin level
- C. Stool occult blood test
- D. Gastric analysis testing
Correct Answer: B
Rationale: Jaundice is caused by the elevation of bilirubin level associated with red blood cell (RBC) hemolysis. The other tests would not be helpful in monitoring or treating hemolytic anemia.
You may also like to solve these questions
Fifteen minutes after a transfusion of packed red blood cells is started, a patient has symptoms of back pain and dyspnea and a pulse rate of 124 beats/minute. Which of the following actions should the nurse implement initially?
- A. Administer oxygen therapy at a high flow rate.
- B. Obtain a urine specimen to send to the laboratory.
- C. Notify the health care provider about the symptoms.
- D. Disconnect the transfusion and infuse normal saline.
Correct Answer: D
Rationale: The patient's symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.
The nurse is caring for a patient who is hospitalized for treatment of severe hemolytic anemia. Which of the following actions should the nurse implement?
- A. Provide a diet high in vitamin K.
- B. Place the patient on protective isolation.
- C. Alternate periods of rest and activity.
- D. Teach the patient how to avoid injury.
Correct Answer: C
Rationale: Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a high vitamin K diet or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia.
The nurse is caring for a patient with polycythemia vera. Which of the following actions should the nurse implement during treatment?
- A. Place the patient on bed rest.
- B. Administer iron supplements.
- C. Avoid use of aspirin products.
- D. Monitor fluid intake and output.
Correct Answer: D
Rationale: Monitoring hydration status is essential in polycythemia vera to prevent thrombosis due to increased blood viscosity. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis (DVT). Iron is contraindicated in patients with polycythemia vera.
The nurse is caring for a patient who has a history of a transfusion-related acute lung injury (TRALI) and is to receive a transfusion of packed red blood cells (PRBCs). Which of the following actions should the nurse take to decrease the risk for TRALI for this patient?
- A. Infuse the PRBCs slowly over 4 hours.
- B. Transfuse only leukocyte-reduced PRBCs.
- C. Administer the scheduled oral diuretic before the transfusion.
- D. Give the PRN dose of antihistamine before starting the transfusion.
Correct Answer: B
Rationale: TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory condition caused by circulatory overload or by allergic reactions, but they will not prevent TRALI.
The nurse is caring for a patient with acute myelogenous leukemia (AML) who is considering the possibility of treatment with a hematopoietic stem cell transplant (HSCT). Which of the following actions is best for the nurse to implement to assist the patient with treatment decisions?
- A. Emphasize the positive outcomes of a bone marrow transplant.
- B. Discuss the need for adequate insurance to cover post-HSCT care.
- C. Ask the patient whether there are any questions or concerns about HSCT.
- D. Explain that a cure is not possible with any other treatment except HSCT.
Correct Answer: C
Rationale: Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and also will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.