Nokea
The nurse is preparing to administer a unit of platelets to an adult patient. When administering this blood product, which of the following actions should the nurse perform?
- A. Administer the platelets as rapidly as the patient can tolerate.
- B. Establish IV access as soon as the platelets arrive from the blood bank.
- C. Ensure that the patient has a patent central venous catheter.
- D. Aspirate 10 to 15 mL of blood from the patients IV immediately following the transfusion.
Correct Answer: A
Rationale: The nurse should infuse each unit of platelets as fast as patient can tolerate to diminish platelet clumping during administration. IV access should be established prior to obtaining the platelets from the blood bank. A central line is appropriate for administration, but peripheral IV access (22-gauge or larger) is sufficient. There is no need to aspirate after the transfusion.
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A patient has been scheduled for a bone marrow biopsy and admits to the nurse that she is worried about the pain involved with the procedure. What patient education is most accurate?
- A. Youll be given painkillers before the test, so there wont likely be any pain?
- B. Youll feel some pain when the needle enters your skin, but none when the needle enters the bone because of the absence of nerves in bone.
- C. Most people feel some brief, sharp pain when the needle enters the bone.
- D. Ill be there with you, and Ill try to help you keep your mind off the pain.
Correct Answer: C
Rationale: Patients typically feel a pressure sensation as the needle is advanced into position. The actual aspiration always causes sharp, but brief pain, resulting from the suction exerted as the marrow is aspirated into the syringe; the patient should be warned about this. Stating, Ill try to help you keep your mind off the pain may increase the patients fears of pain, because this does not help the patient know what to expect.
A patients most recent blood work reveals low levels of albumin. This assessment finding should suggest the possibility of what nursing diagnosis?
- A. Risk for imbalanced fluid volume related to low albumin
- B. Risk for infection related to low albumin
- C. Ineffective tissue perfusion related to low albumin
- D. Impaired skin integrity related to low albumin
Correct Answer: A
Rationale: Albumin is particularly important for the maintenance of fluid balance within the vascular system. Deficiencies nearly always manifest as fluid imbalances. Tissue oxygenation and skin integrity are not normally affected. Low albumin does not constitute a risk for infection.
A patient has come to the OB/GYN clinic due to recent heavy menstrual flow. Because of the patients consequent increase in RBC production, the nurse knows that the patient may need to increase her daily intake of what substance?
- A. Vitamin E
- B. Vitamin D
- C. Iron
- D. Magnesium
Correct Answer: C
Rationale: To replace blood loss, the rate of red cell production increases. Iron is incorporated into hemoglobin. Vitamins E and D and magnesium do not need to be increased when RBC production is increased.
A patient has been diagnosed with a lymphoid stem cell defect. This patient has the potential for a problem involving which of the following?
- A. Plasma cells
- B. Neutrophils
- C. Red blood cells
- D. Platelets
Correct Answer: A
Rationale: A defect in a myeloid stem cell can cause problems with erythrocyte, leukocyte, and platelet production. In contrast, a defect in the lymphoid stem cell can cause problems with T or B lymphocytes, plasma cells (a more differentiated form of B lymphocyte), or natural killer (NK) cells.
A patients low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should the nurse perform?
- A. Have the patient identify his or her blood type in writing.
- B. Ensure that the patient has granted verbal consent for transfusion.
- C. Assess the patients vital signs to establish baselines.
- D. Facilitate insertion of a central venous catheter.
Correct Answer: C
Rationale: Prior to a transfusion, the nurse must take the patients temperature, pulse, respiration, and BP to establish a baseline. Written consent is required and the patients blood type is determined by type and cross match, not by the patients self-declaration. Peripheral venous access is sufficient for blood transfusion.