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The nurse is caring for a patient who has been receiving a heparin infusion and warfarin for a deep vein thrombosis (DVT) with a diagnosis of heparin-induced thrombocytopenia (HIT). Which of the following actions should the nurse include in the plan of care?
- A. Use low-molecular-weight heparin (LMWH) only.
- B. Flush all intermittent IV lines using normal saline.
- C. Administer platelet transfusions.
- D. Teach the patient that heparin cannot be used in the future.
Correct Answer: D
Rationale: All heparin is discontinued when HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150 x 10^9/L. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.
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The hemophilia clinic nurse receives a call from a patient with hemophilia to discuss all of these problems. Which of the following problems is most important to communicate to the health care provider?
- A. Joint swelling
- B. Painful hematuria
- C. Multiple bruises
- D. Dark tarry stools
Correct Answer: D
Rationale: Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury, but are not indicators of possible serious blood loss.
Which of the following nursing interventions should be included in the care plan for a patient with immune thrombocytopenic purpura (ITP)?
- A. Assign the patient to a private room.
- B. Avoid intramuscular (IM) injections.
- C. Use rinses rather than a toothbrush for oral care.
- D. Restrict activity to passive and active range of motion.
Correct Answer: B
Rationale: IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.
Which of the following actions should the nurse include in the care plan for a hospitalized patient who is neutropenic?
- A. Avoid any IM or subcutaneous injections.
- B. Check the oral temperature every 4 hours.
- C. Omit all fruits or vegetables from the diet.
- D. Place a 'No Visitors' sign on the patient door.
Correct Answer: B
Rationale: The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim. The number of visitors may be limited and visitors with communicable diseases should be avoided, but a 'no visitors' policy is not needed.
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.
After receiving change-of-shift report for the following four patients with neutropenia, which patient should the nurse assess first?
- A. 66-year-old who has white pharyngeal lesions
- B. 35-year-old who has a fever of 38.2°C (100.8°F)
- C. 36-year-old who has frequent explosive diarrhea
- D. 23-year old who is complaining of severe fatigue
Correct Answer: B
Rationale: Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problems.