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Which statement is the scientific rationale for infusing a unit of blood in less than four (4) hours?
- A. The blood will coagulate if left out of the refrigerator for greater than four (4) hours.
- B. The blood has the potential for bacterial growth if allowed to infuse longer.
- C. The blood components begin to break down after four (4) hours.
- D. The blood will not be affected; this is a laboratory procedure.
Correct Answer: B
Rationale: Blood must infuse within 4 hours (B) to minimize bacterial growth risk. Coagulation (A) is not primary, components (C) degrade minimally, and lab procedure (D) is incorrect.
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The nurse is caring for a client in a sickle cell crisis. Which is the pain regimen of choice to relieve the pain?
- A. Frequent aspirin (acetylsalicylic acid) and a nonnarcotic analgesic.
- B. Motrin (ibuprofen), a nonsteroidal anti-inflammatory drug (NSAID), prn.
- C. Demerol (meperidine), a narcotic analgesic, every four (4) hours.
- D. Morphine, a narcotic analgesic, every two (2) to three (3) hours prn.
Correct Answer: D
Rationale: Morphine PRN (D) is preferred for severe SCA crisis pain, titrated to relief. Aspirin (A) and ibuprofen (B) are insufficient and risk bleeding, and meperidine (C) risks seizures.
The client diagnosed with non-Hodgkin's lymphoma is scheduled for a lymphangiogram. Which information should the nurse teach?
- A. The scan will identify any malignancy in the vascular system.
- B. Radiopaque dye will be injected between the toes.
- C. The test will be done similar to a cardiac angiogram.
- D. The test will be completed in about five (5) minutes.
Correct Answer: B
Rationale: Lymphangiogram involves dye injection between toes (B) to visualize lymphatics. It’s not vascular (A), unlike cardiac angiogram (C), and takes longer than 5 minutes (D).
The nurse is preparing the client for a bone marrow biopsy of the iliac crest. Place the nurse’s actions in order of priority.
- A. Premedicate with lorazepam
- B. Obtain a signed informed consent
- C. Position prone and provide emotional support
- D. Verify that the HCP has explained the procedure
- E. Check for signs of bleeding every 2 hours for 24 hours
- F. Teach what may be expected during the procedure
Correct Answer: D, F, B, A, C, E:
Rationale: Verify that the HCP has explained the procedure. The HCP should include the purpose, intended outcomes, and potential complications. F. Teach what may be expected during the procedure, including that pressure or discomfort may be experienced. B. Obtain a signed informed consent. This is obtained only after the HCP has met with the client and teaching is completed. A. Premedicate with lorazepam (Ativan). Midazolam (Versed) is another option for sedation. A local anesthetic is used at the site, and some clients may not need sedation. C. Position prone and provide emotional support. The client should be prone because the iliac crest is the site being used for this biopsy, but the position will vary with the site. Holding the client’s hand and using guided imagery help support the client. E. Check for signs of bleeding every 2 hours for 24 hours. A pressure dressing is applied by the HCP after the procedure. Ice can be applied to reduce bruising and for comfort.
The nurse is discussing dietary sources of iron with a client who has iron deficiency anemia. Which menu, if selected by the client, indicates the best understanding of the diet?
- A. Milkshake, hot dog, and beets
- B. Beef steak, spinach, and grape juice
- C. Chicken salad, green peas, and coffee
- D. Macaroni and cheese, coleslaw, and lemonade
Correct Answer: B
Rationale: Beef, spinach, and grape juice contain iron. Milk contains no iron, and the other options have lower iron content.
The client with COPD has developed polycythemia vera, and the nurse completes teaching on measures to prevent complications. During a home visit, the nurse evaluates that the client is correctly following the teaching when which actions are noted?
- A. Tells the nurse about discontinuing iron supplements.
- B. States increasing alcohol intake to decrease blood viscosity.
- C. Presents a record that shows a daily fluid intake of 3000 mL.
- D. Discusses yesterday’s phlebotomy treatment to remove blood.
- E. Shows the nurse 3 menu plan for eating three large meals daily.
- F. Wears antiembolic stockings and sits in a recliner with legs uncrossed
Correct Answer: A, C, D, F
Rationale: Iron supplements, including those in multi-vitamins, should be avoided because the iron stimulates RBC production. B. Alcohol increases the risk of bleeding. C. Increasing fluid intake to 3000 mL daily will help decrease blood viscosity. D. Phlebotomy is performed on a routine or intermittent basis to diminish blood viscosity, deplete iron stores, and decrease the client’s ability to manufacture excess erythrocytes. E. Frequent, small meals are better tolerated, especially if the liver is involved. F. Elevating the legs, avoiding constriction or crossing the legs, and wearing antiembolic stockings help prevent DVT.