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The nurse is caring for a patient receiving a transfusion of packed red blood cells who develops chills, fever, headache, and anxiety 30 minutes after the transfusion is started. After stopping the transfusion, which of the following actions is priority?
- A. Draw blood for a new crossmatch.
- B. Send a urine specimen to the laboratory.
- C. Give the PRN diphenhydramine.
- D. Administer the PRN acetaminophen.
Correct Answer: D
Rationale: The patient's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.
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All of these patients call the outpatient clinic and ask to make an appointment as soon as possible. Which of the following patients should the nurse schedule to be seen first?
- A. 19-year-old with no previous health problems who has a nontender lump in the axilla
- B. 46-year-old with sickle cell anemia who says 'that my eyes always look sort of yellow'
- C. 21-year-old with hemophilia who wants to learn how to self-administer factor VII replacement
- D. 50-year-old with early-stage persistent lymphocytic leukemia who has complaints of persistent fatigue
Correct Answer: A
Rationale: The patient's age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently.
The nurse has finished teaching a patient about taking oral ferrous sulphate. Which of the following patient statements indicates that additional instruction is needed?
- A. I will call the doctor if my stools start to turn black.
- B. I will take a stool softener if I feel constipated occasionally.
- C. I should take the iron with orange juice about an hour before eating.
- D. I should increase my fluid and fibre intake while I am taking the iron tablets.
Correct Answer: A
Rationale: It is normal for the stools to appear black when a patient is taking iron and the patient should not call the doctor about this. The other patient statements are correct.
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.
A routine complete blood count indicates that a patient may have myelodysplastic syndrome. At this time, which of the following information should the nurse include in the teaching plan?
- A. Packed red blood cells (PRBCs) transfusion
- B. Bone marrow biopsy
- C. Filgrastim administration
- D. Erythropoietin administration
Correct Answer: B
Rationale: Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.
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.