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The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)?
- A. Verify the patient identification (ID) according to hospital policy
- B. Obtain the temperature, blood pressure, and pulse before the transfusion
- C. Double-check the product numbers on the PRBCs with the patient ID band
- D. Monitor the patient for shortness of breath or chest pain during the transfusion
Correct Answer: B
Rationale: The correct answer is B. Unlicensed assistive personnel (UAP) can obtain the temperature, blood pressure, and pulse before a transfusion as their education includes measurement of vital signs. UAP would then report the vital signs to the registered nurse (RN). Option A is typically a nursing responsibility to ensure patient safety and avoid errors in patient identification. Option C involves cross-checking important details and ensuring accuracy, which is usually performed by nursing staff to prevent errors. Option D requires monitoring for potential adverse reactions during the transfusion, which is a nursing responsibility due to the need for assessment and intervention in case of complications.
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The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient?
- A. Are you taking any oral contraceptives?
- B. Have you been prescribed antiseizure drugs?
- C. Do you take medication containing salicylates?
- D. How long have you been taking antihypertensive drugs?
Correct Answer: C
Rationale: The correct answer is C: 'Do you take medication containing salicylates?' Petechiae are tiny, pinpoint, red or purple spots on the skin due to bleeding under the skin. Salicylates, which are found in medications like aspirin, interfere with platelet function and can lead to petechiae and ecchymoses. Asking about salicylate-containing medications is crucial in this situation. Choices A, B, and D are incorrect because they are not directly related to the development of petechiae.
A patient who has immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the healthcare provider before obtaining and administering platelets?
- A. Platelet count is 42,000/µL
- B. Petechiae are present on the chest
- C. Blood pressure (BP) is 94/56 mm Hg
- D. Blood is oozing from the venipuncture site
Correct Answer: A
Rationale: The correct answer is A. Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/µL unless the patient is actively bleeding. In this scenario, the platelet count of 42,000/µL is not significantly low to warrant a platelet transfusion without active bleeding. Consulting with the healthcare provider is essential before giving the transfusion to ensure the appropriateness of the treatment. Choices B, C, and D are not directly related to the need for consulting before a platelet transfusion. Petechiae, low blood pressure, and oozing from the venipuncture site are common findings in patients with ITP and may not necessarily contraindicate a platelet transfusion at this platelet count.
Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first?
- A. A 44-year-old with sickle cell anemia who reports his eyes always look somewhat yellow
- B. A 23-year-old with no previous health problems who has a nontender lump in the axilla
- C. A 50-year-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue
- D. A 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement
Correct Answer: B
Rationale: The patient's young age and the presence of a nontender lump in the axilla raise concerns for possible lymphoma, which requires prompt evaluation and treatment. This patient should be seen first to rule out any serious underlying condition. Choice A is less urgent as yellowish eyes in sickle cell anemia may be due to jaundice but not necessarily an acute issue. Choice C, a 50-year-old with chronic fatigue related to early-stage chronic lymphocytic leukemia, is a known condition that can be managed on a routine basis. Choice D, a 19-year-old with hemophilia wanting to self-administer factor VII replacement, is important but less urgent compared to the potential lymphoma presentation in choice B.
Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy?
- A. Platelet count
- B. Reticulocyte count
- C. Total lymphocyte count
- D. Absolute neutrophil count
Correct Answer: D
Rationale: The correct answer is D, Absolute neutrophil count. Filgrastim (Neupogen) works by stimulating the production and function of neutrophils. Therefore, monitoring the Absolute neutrophil count is crucial to assess the effectiveness of filgrastim in increasing neutrophil levels. Choices A, B, and C are incorrect because platelet count, reticulocyte count, and total lymphocyte count do not directly reflect the effectiveness of filgrastim in increasing neutrophils, which are essential in fighting infections during chemotherapy.
The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take before this procedure?
- A. Check for any iodine allergy.
- B. Insert a large-bore IV catheter.
- C. Administer prescribed sedatives.
- D. Assist the patient to a flat position.
Correct Answer: D
Rationale: Before a liver and spleen scan, it is essential to assist the patient to a flat position. This position helps obtain clear images of the liver and spleen. Checking for iodine allergy (Choice A) is more relevant for procedures involving contrast dye, not a liver and spleen scan. Inserting a large-bore IV catheter (Choice B) may not be necessary for this specific procedure. Administering sedatives (Choice C) is not typically required for a liver and spleen scan, as the patient needs to remain still during the procedure.