Nokea
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.
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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.
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.
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.
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 septicemia who develops prolonged bleeding from venipuncture sites and blood in the stools. Which of the following actions is most important for the nurse to take?
- A. Notify the patient's health care provider.
- B. Give the ordered dose of warfarin.
- C. Avoid unnecessary venipunctures.
- D. Give prescribed proton-pump inhibitors.
Correct Answer: A
Rationale: The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions also are appropriate, but the most important action should be to notify the physician so that DIC treatment can be initiated rapidly.