Nokea
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.
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The nurse is caring for a patient with acute myelogenous leukemia who is receiving outpatient chemotherapy and develops an absolute neutrophil count of 0.9 x 10^9/L. Which of the following actions by the nurse in the outpatient clinic is best?
- A. Discuss the need for hospital admission to treat the neutropenia.
- B. Plan to discontinue the chemotherapy until the neutropenia resolves.
- C. Teach the patient how to administer filgrastim injections at home.
- D. Obtain a high-efficiency particulate air (HEPA) filter for the patient for home use.
Correct Answer: C
Rationale: The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count less than 0.5 x 10^9/L), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient's home environment.
All of these patients are waiting to be admitted by the emergency department nurse. Which one of the following requires the most rapid assessment and care by the nurse?
- A. The patient with hemochromatosis who has symptoms of abdominal pain
- B. The patient with thrombocytopenia who has blood oozing after having a tooth extracted
- C. The patient with chemotherapy-induced neutropenia who has a temperature of 38.2°C (100.8°F)
- D. The patient with a history of sickle cell anemia who has had nausea and diarrhea for 24 hours
Correct Answer: C
Rationale: A neutropenic patient with a fever is assumed to have an infection and developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.
Which of the following menu choices indicate that the patient understands the nurse's teaching about best dietary choices for iron-deficiency anemia?
- A. Omelet and whole wheat toast
- B. Cantaloupe and cottage cheese
- C. Strawberry and banana fruit plate
- D. Cornmeal muffin and orange juice
Correct Answer: A
Rationale: Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies, but are not the best choice for a patient with iron-deficiency anemia.
Which of the following newly admitted patients should the nurse assign as a roommate for a patient who has aplastic anemia?
- A. A patient with severe heart failure
- B. A patient who has viral pneumonia
- C. A patient who has right leg cellulitis
- D. A patient with multiple abdominal drains
Correct Answer: A
Rationale: Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.
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.