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Which of the following assessment data obtained by the nurse when caring for a patient with thrombocytopenia should be immediately communicated to the health care provider?
- A. The platelet count is 52 x 10^9/L.
- B. The patient is difficult to arouse.
- C. There are large bruises on the back.
- D. There are purpura on the oral mucosa.
Correct Answer: B
Rationale: Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life-threatening and requires immediate action. The other information should be documented and reported, but would not be unusual in a patient with thrombocytopenia.
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The nurse is planning discharge teaching for a patient who was admitted with neutropenia. Which of the following instructions should the nurse include?
- A. Limit fluids to 2-3 litres a day.
- B. Include eggs and fish in the diet.
- C. Avoid exposure to crowds as much as possible.
- D. Drink only one or two caffeinated beverages daily.
Correct Answer: C
Rationale: Exposure to crowds increases the risk of infection in neutropenic patients. Limiting fluids or caffeinated beverages is not necessary, and eggs and fish are acceptable in the diet unless otherwise contraindicated.
The nurse is admitting a patient with type A hemophilia who has severe pain and swelling in the right knee. Which of the following actions should the nurse implement initially?
- A. Immobilize the knee
- B. Apply heat to the joint
- C. Assist the patient with light weight bearing
- D. Perform passive range of motion to the knee
Correct Answer: A
Rationale: The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.
After receiving change-of-shift report for the following four patients with neutropenia, which patient should the nurse assess first?
- A. 66-year-old who has white pharyngeal lesions
- B. 35-year-old who has a fever of 38.2°C (100.8°F)
- C. 36-year-old who has frequent explosive diarrhea
- D. 23-year old who is complaining of severe fatigue
Correct Answer: B
Rationale: Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problems.
Which of the following nursing actions should the nurse include in the plan of care for a patient admitted with multiple myeloma?
- A. Monitor fluid intake and output.
- B. Administer calcium supplements.
- C. Assess lymph nodes for enlargement.
- D. Limit weight bearing and ambulation.
Correct Answer: A
Rationale: A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient's calcium level and are not used.
Which of the following laboratory information should the nurse monitor to detect heparin-induced thrombocytopenia (HIT) in a patient who is receiving a continuous heparin infusion?
- A. Prothrombin time
- B. Erythrocyte count
- C. Fibrinogen degradation products
- D. Activated partial thromboplastin time
Correct Answer: D
Rationale: Platelet aggregation in HIT causes neutralization of heparin so that the activated partial thromboplastin time will be shorter and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.