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Which laboratory result would the nurse expect in the client diagnosed with DIC?
- A. A decreased prothrombin time.
- B. A low fibrinogen level.
- C. An increased platelet count.
- D. An increased white blood cell count.
Correct Answer: B
Rationale: DIC consumes clotting factors, lowering fibrinogen (B). PT is prolonged (A), platelets decrease (C), and WBCs (D) are nonspecific.
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The nurse and an unlicensed assistive personnel (UAP) are caring for clients on an oncology floor. Which nursing task would be delegated to the UAP?
- A. Assess the urine output on a client who has had a blood transfusion reaction.
- B. Take the first 15 minutes of vital signs on a client receiving a unit of PRBCs.
- C. Auscultate the lung sounds of a client prior to a transfusion.
- D. Assist a client who received 10 units of platelets in brushing the teeth.
Correct Answer: B
Rationale: Taking initial vital signs (B) during transfusion is within UAP scope. Assessing urine (A), lung sounds (C), and brushing teeth post-platelets (D) require nursing judgment.
The client is symptomatic with a Hgb of 7.8 g/dL, but refuses blood and blood products transfusions for religious reasons. The nurse should prepare the client that the HCP may prescribe which alternatives?
- A. Epoetin alfa
- B. Folic acid
- C. Albumin
- D. Platelets
- E. Fresh frozen plasma
- F. Granulocytes
Correct Answer: A, B,
Rationale: Epoetin alfa (erythropoietin growth factor; Procrit) promotes erythropoiesis (production of RBCs), thus decreasing the need for transfusions. B. Folic acid promotes erythropoiesis and production of WBCs and platelets. C. Albumin is a blood product. D. Platelets are blood products. E. Plasma is a blood product. F. Granulocytes are blood products.
The client is diagnosed with polycythemia vera. The nurse would prepare to perform which intervention?
- A. Type and crossmatch for a transfusion.
- B. Assess for petechiae and purpura.
- C. Perform phlebotomy of 500 mL of blood.
- D. Monitor for low hemoglobin and hematocrit.
Correct Answer: C
Rationale: Polycythemia vera requires phlebotomy (C) to reduce blood viscosity. Transfusions (A) worsen hyperviscosity, petechiae (B) are for thrombocytopenia, and Hb/Hct (D) are elevated.
The client’s CBC indicates an RBC 6 (x106/mm3), Hb 14.2 g/dL, Hct 42%, and platelets 69 (x103/mm3). Which intervention should the nurse implement?
- A. Teach the client to use a soft-bristle toothbrush.
- B. Monitor the client for elevated temperature.
- C. Check the client’s blood pressure.
- D. Hold venipuncture sites for one (1) minute.
Correct Answer: A
Rationale: Platelets 69,000 indicate thrombocytopenia; a soft-bristle toothbrush (A) prevents gum bleeding. Fever (B), BP (C), and brief pressure (D) are insufficient for bleeding risk.
The nurse discusses the self-care guidelines to minimize the side effects of radiation on the skin. Which actions to reduce radiation skin reactions should the nurse explain to the client?
- A. Wear loose-fitting, soft clothing over the treated skin.
- B. Use a straight-edged razor to shave hair in the treated area.
- C. Swim only in swimming pools to avoid stagnant water.
- D. Use only skin-care products suggested by the radiation staff.
- E. Apply skin products immediately after radiation treatment.
- F. Wash treated area gently with lukewarm water and mild soap.
Correct Answer: A, D, F,
Rationale: Wearing loose-fitting, soft clothing over the treated skin is a recommended skin-care activity to reduce radiation skin reactions. B. The use of an electric, not a straight-edged, razor for shaving a treated area is recommended. C. Clients are advised to avoid swimming in chlorinated water. D. Using only skin-care products suggested by the radiation staff is a recommended skin-care activity to reduce radiation skin reactions. E. Clients are advised to delay the application of skin-care products within 4 hours of radiation treatment. F. Washing the treated area gently with lukewarm water and mild soap is a recommended skin-care activity to reduce radiation skin reactions.