Nokea
The nurse is caring for a patient with immune thrombocytopenic purpura (ITP) who has a prescription for a platelet transfusion. Which of the following patient information will cause the nurse to question the transfusion order?
- A. The platelet count is 52 x 10^9/L.
- B. Blood pressure is 94/56 mm Hg.
- C. Blood is oozing from the venipuncture site.
- D. Petechiae are present on the chest and arms.
Correct Answer: A
Rationale: Platelet transfusions are not usually indicated unless the patient is actively bleeding, so the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP is occurring and support the need for the platelet transfusion.
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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 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 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 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 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.