Nokea
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.
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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 caring for a patient with a sickle cell crisis. While caring for the patient during the crisis, which of the following actions is priority?
- A. Limit the patient's intake of oral and IV fluids.
- B. Evaluate the effectiveness of opioid analgesics.
- C. Encourage the patient to ambulate as much as tolerated.
- D. Teach the patient about high-protein, high-calorie foods.
Correct Answer: B
Rationale: Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.
The nurse is caring for a patient with acute myelogenous leukemia (AML) who has induction therapy prescribed and the patient asks the nurse whether the planned chemotherapy will be worth undergoing. Which of the following responses by the nurse is best?
- A. If you do not want to have chemotherapy, there are other options for treatment such as stem cell transplantation.
- B. The decision about chemotherapy is one that you and the doctor need to make rather than asking what I would do.
- C. You don't need to make a decision about treatment right now since leukemias in adults tend to progress quite slowly.
- D. The adverse effects of the chemotherapy are difficult, but AML frequently does go into remission with chemotherapy.
Correct Answer: D
Rationale: This response uses therapeutic communication by addressing the patient's question and giving accurate information. The other responses either give inaccurate information or fail to address the patient's question, which will discourage the patient from asking the nurse for information.
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.
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.