Nokea
The nurse notes that a patient's gaping wound is developing a blood clot. Which body substance is responsible for this clot formation?
- A. Plasma
- B. Platelets
- C. Red blood cells
- D. White blood cells
Correct Answer: B
Rationale: Platelets are responsible for clot formation in the body. When a wound occurs, platelets are activated and adhere to the site, forming a plug to stop bleeding. They release chemicals to further enhance clot formation. Plasma is the liquid component of blood, red blood cells carry oxygen, and white blood cells are part of the immune system, none of which are directly involved in clot formation.
You may also like to solve these questions
A patient who is undergoing consolidation therapy for the treatment of leukemia has been experiencing debilitating fatigue. How can the nurse best meet this patient's needs for physical activity?
- A. Teach the patient about the risks of immobility and the benefits of exercise.
- B. Assist the patient to a chair during awake times, as tolerated.
- C. Collaborate with the physical therapist to arrange for stair exercises.
- D. Teach the patient to perform deep breathing and coughing exercises.
Correct Answer: B
Rationale: The correct answer is B because assisting the patient to a chair during awake times allows for gradual physical activity, promoting mobility without overwhelming the patient. This option supports the patient's need for movement while considering their current level of fatigue.
A is incorrect because educating the patient about the benefits of exercise may not be feasible or appropriate given the patient's current fatigue levels.
C is incorrect as stair exercises may be too strenuous for a patient experiencing debilitating fatigue, potentially leading to further exhaustion and risk of injury.
D is incorrect because deep breathing and coughing exercises primarily focus on respiratory health and may not directly address the patient's need for physical activity to combat fatigue.
You are consulted on a 4-year-old girl who is newly diagnosed with standard-risk pre-B acute lymphoblastic leukemia. After reviewing her previous complete blood examinations, you note she has had a platelet count ranging from 80,000 to 100,000 cells/mcL over the past 2 years. Her father mentions that he has also been told he has mild thrombocytopenia. You suspect the child may have a cancer predisposition syndrome. Which sample should you send for analysis, and which gene is most likely implicated?
- A. Skin fibroblasts to evaluate the RUNX1 gene
- B. Skin fibroblasts to evaluate the ETV6 gene
- C. Buccal swab to evaluate the RUNX1 gene
- D. Buccal swab to evaluate the ETV6 gene
Correct Answer: B
Rationale: The correct answer is B: Skin fibroblasts to evaluate the ETV6 gene.
1. ETV6 gene mutations are associated with inherited thrombocytopenia, making it a likely candidate in this case.
2. Skin fibroblasts are needed for genetic analysis as they provide a reliable sample for detecting genetic mutations.
3. RUNX1 gene mutations are also linked to thrombocytopenia but are more commonly associated with familial platelet disorder with predisposition to acute myeloid leukemia.
4. Buccal swabs are not ideal for evaluating genetic mutations related to thrombocytopenia as they may not provide sufficient genetic material for accurate testing.
A nursing student is caring for a patient with acute myeloid leukemia who is preparing to undergo induction therapy. In preparing a plan of care for this patient, the student should assign the highest priority to which nursing diagnoses?
- A. Activity Intolerance
- B. Risk for Infection
- C. Acute Confusion
- D. Risk for Spiritual Distress
Correct Answer: B
Rationale: The correct answer is B: Risk for Infection. During induction therapy for acute myeloid leukemia, the patient's immune system is compromised, making them highly susceptible to infections. Therefore, the highest priority nursing diagnosis should be addressing and preventing infections. This includes monitoring for signs of infection, implementing proper infection control measures, educating the patient and family on infection prevention, and administering prophylactic antibiotics as needed.
Choice A (Activity Intolerance) may be a concern due to the patient's underlying condition and treatment, but preventing infections takes precedence as it can lead to life-threatening complications. Choice C (Acute Confusion) and Choice D (Risk for Spiritual Distress) are important considerations but do not pose an immediate threat to the patient's health and safety compared to the risk of infection.
A patient reports severe abdominal cramping and diarrhea. Assessment reveals a temperature of 102°F (38.8°C) and pulse of 82 beats/min. Results of a complete blood count reveal lower than normal segmented and banded neutrophils and higher than normal lymphocytes. Which type of infection does the nurse suspect this patient is most likely experiencing?
- A. Viral
- B. Fungal
- C. Parasitic
- D. Bacterial
Correct Answer: A
Rationale: The correct answer is A: Viral. The patient's symptoms (abdominal cramping, diarrhea, fever) are consistent with a viral infection, such as gastroenteritis. The lower segmented and banded neutrophils indicate a viral infection, as viruses often target lymphocytes. The higher lymphocyte count is a characteristic response to viral infections. Other choices are incorrect as fungal, parasitic, and bacterial infections typically present with different symptoms and laboratory findings.
A 10-year-old patient with aplastic anemia, who is blood type B negative, is receiving a red blood cell transfusion. About 10 minutes after the transfusion starts, the patient develops anxiety and lower back pain. The transfusion continues for another 5 minutes until it is stopped when he develops a temperature of 40 °C with chills and rigors. A transfusion reaction work-up is most likely to reveal what findings?
- A. Spherocytes on peripheral blood smear
- B. Gram-negative Bacillus on gram stain of remaining RBC unit
- C. Chest x-ray with bilateral pulmonary infiltrates that are new compared to an x-ray done last week
- D. DAT positive for C3
Correct Answer: D
Rationale: The correct answer is D because in this scenario, the patient is experiencing symptoms of a transfusion reaction, likely a hemolytic transfusion reaction due to ABO incompatibility. The presence of a positive Direct Antiglobulin Test (DAT) for C3 indicates complement activation, supporting the diagnosis.
Choice A (Spherocytes on peripheral blood smear) is incorrect as spherocytes are seen in autoimmune hemolytic anemia, not typically in transfusion reactions.
Choice B (Gram-negative Bacillus on gram stain of remaining RBC unit) is unlikely as the symptoms are more indicative of a hemolytic reaction rather than an infection.
Choice C (Chest x-ray with bilateral pulmonary infiltrates) is suggestive of transfusion-related acute lung injury (TRALI), but the symptoms described in the question (fever, chills, rigors) are more indicative of a hemolytic reaction rather than TRALI.