Ati lpn med surg haematology
Total Questions : 32
Showing 25 questions, Sign in for moreA nurse is reinforcing teaching with a client has a new diagnosis of aplastic anemia. When discussing the pathology of this disease, which of the following instructions should the nurse include in the teaching?
Explanation
A. "Aplastic anemia results from decreased bone marrow production of RBCs." Aplastic anemia is characterized by the failure of bone marrow to produce adequate red blood cells (RBCs), white blood cells, and platelets. This results in pancytopenia, which increases the risk of infections, anemia, and bleeding.
B. "Aplastic anemia is directly related to impaired liver function." Aplastic anemia is not related to liver function; it originates from the bone marrow’s inability to produce sufficient blood cells.
C. "Aplastic anemia is associated with the decreased intake of iron." Aplastic anemia is not caused by iron deficiency; it is primarily due to bone marrow failure. Iron deficiency anemia, on the other hand, results from a lack of iron intake or absorption.
D. "Aplastic anemia results in an increased rate of RBC destruction." Increased RBC destruction is characteristic of hemolytic anemia, not aplastic anemia.
The nurse is caring for a patient with a platelet count of <20,000/mm3 (150,000-400000). Which of the following precautions should the nurse take in providing care for this patient?
Explanation
A. Report fever to MD ASAP: While fever in any immunocompromised patient should be reported, it does not directly address precautions related to low platelet counts and bleeding risks.
B. Use a soft toothbrush with oral care: With a low platelet count, the patient is at risk for bleeding. Using a soft toothbrush minimizes the risk of gum injury and bleeding, a critical safety measure for thrombocytopenic patients.
C. Drink hot liquids TID: Hot liquids are not recommended as they may cause mouth or esophageal burns, increasing bleeding risk if the mucosa is damaged. Tepid or cold fluids are safer.
D. Recommend straight edge razor for shaving: Patients with low platelets should use an electric razor to avoid cuts, as any bleeding is harder to control in thrombocytopenic individuals.
A nurse is collecting data on a client who is to receive a blood transfusion. Which of the following data is the nurse's priority before the transfusion begins?
Explanation
A. Skin color: While skin color can show signs of reactions, it is a secondary measure. Temperature changes can be more immediately significant in assessing transfusion reactions.
B. Temperature: Temperature is the priority because a fever can indicate an infection or may develop as a sign of a transfusion reaction. Monitoring baseline temperature helps quickly identify febrile reactions to the transfusion.
C. Hemoglobin level: Although important to verify, the hemoglobin level is part of the overall assessment but does not directly predict or prevent transfusion reactions.
D. Fluid intake: Fluid intake is monitored for fluid overload risk but is not as immediate in the prevention of transfusion reactions.
A nurse is reinforcing teaching with a client who is to have a bone marrow aspiration and biopsy. The nurse should tell the client that, in addition to the iliac crest, a common site for this procedure is which of the following?
Explanation
A. Hip: While “hip” can sometimes colloquially refer to the iliac crest, it is not commonly used to describe the specific site for aspiration outside of the iliac crest.
B. Cervical spine: The cervical spine is not a site used for bone marrow aspiration due to its inaccessibility and proximity to critical structures.
C. Sternum: The sternum is a common site for bone marrow aspiration in adults as it provides direct access to the marrow.
D. Humerus: The humerus is generally not used for bone marrow aspirations as it does not provide as accessible or large an area for aspiration.
A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?
Explanation
A. Pulmonary congestion: Pulmonary congestion is associated more with fluid overload or transfusion-associated circulatory overload (TACO), not an acute hemolytic reaction.
B. Urticaria: Urticaria (hives) is more typical of a mild allergic reaction rather than an acute hemolytic reaction.
C. Vomiting: Although nausea and vomiting may occur in various transfusion reactions, it is not specific to an acute hemolytic reaction like low back pain is.
D. Low back pain: Low back pain, often around the kidneys, is a classic sign of an acute hemolytic reaction due to the breakdown of RBCs and the release of hemoglobin into the bloodstream, which can lead to renal damage. This reaction is a medical emergency requiring immediate intervention.
A nurse is planning care for a client who is to receive one unit of packed RBCs. Within which of the following time spans must the nurse complete the infusion?
Explanation
A. 2 hr: While some patients may tolerate faster infusion rates, the maximum safe time is 4 hours, and there is no requirement to complete it in 2 hours.
B. 8 hr: Blood cannot be left out for 8 hours due to the increased risk of bacterial growth and contamination.
C. 6 hr: Infusing blood over 6 hours exceeds the safe time limit and poses a risk of bacterial contamination.
D. 4 hr: To reduce the risk of bacterial contamination, a unit of packed RBCs must be transfused within 4 hours of starting the infusion. This time frame ensures that the blood remains safe for the patient while minimizing exposure to room temperature.
A nurse is reviewing data for a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
Explanation
A. Progressive increase in platelet production: In DIC, platelets are rapidly consumed, not increased, due to widespread clotting in the blood vessels.
B. Excessive thrombosis and bleeding: DIC is a complex condition where there is widespread activation of the clotting cascade, leading to excessive clotting and subsequent depletion of platelets and clotting factors, resulting in both thrombosis and bleeding.
C. Immediate sodium and fluid retention: Sodium and fluid retention are not specific findings in DIC; they may occur in cases of renal or heart failure but are unrelated to the clotting issues in DIC.
D. Increased clotting factors: In DIC, clotting factors are depleted as they are used up in widespread clotting, leading to bleeding when factors are exhausted.
The nurse is caring for a patient who must undergo a splenectomy for treatment for idiopathic thrombocytopenic purpura (ITP). Which of the following statements best describes the rationale for the splenectomy?
Explanation
A. The spleen is the primary site for platelet destruction. In ITP, the spleen often sequesters and destroys platelets, leading to low platelet levels. Removing the spleen reduces platelet destruction and can help increase platelet counts in affected patients.
B. The spleen is at risk for infection due to the critical loss of WBCs. While infection risk increases after splenectomy, this is not the rationale for the procedure. The spleen does play a role in immune function, but splenectomy is indicated for reducing platelet destruction, not infection prevention.
C. Your spleen is making too many platelets. The spleen does not produce platelets; rather, it filters and sometimes destroys them, particularly in ITP. This choice does not accurately reflect the pathophysiology of ITP.
D. The spleen causes an overabundance of immature platelets. The spleen does not cause an increase in immature platelets. In ITP, platelets are destroyed, not overproduced.
The nurse is caring for a patient with a clotting disorder. Which should the nurse plan to administer?
Explanation
A. Cryoprecipitates: Cryoprecipitates contain fibrinogen, factor VIII, von Willebrand factor, and factor XIII, and are typically used for patients with specific factor deficiencies, such as hemophilia or fibrinogen deficiency, rather than general clotting disorders.
B. Frozen Packed Red Blood Cells (PRBCs): PRBCs are primarily used to treat anemia and to increase oxygen-carrying capacity, not to correct clotting factor deficiencies.
C. Fresh frozen plasma (FFP): Fresh frozen plasma (FFP) contains clotting factors and is administered to patients with clotting disorders to help manage bleeding by replenishing these factors.
D. Platelets: Platelets are administered to patients with thrombocytopenia or platelet dysfunction, not to replace clotting factors as needed in general clotting disorders.
A nurse is assisting in planning care for a client who has advanced multiple myeloma. When planning care the nurse should recognize that the client is at risk for which of the following complications?
Explanation
A. Myxedema: Myxedema is associated with hypothyroidism, not multiple myeloma.
B. Pathologic fracture: Advanced multiple myeloma causes bone demineralization and osteolytic lesions, making bones fragile and increasing the risk for pathologic fractures.
C. Retinopathy: Retinopathy is commonly associated with diabetes or hypertension, not with multiple myeloma.
D. Gastrointestinal bleeding: Gastrointestinal bleeding is not a typical complication of multiple myeloma.
The nurse is reviewing laboratory values for a female patient and notes a hemoglobin level of 8.2 g/100 mL (12-16) and a hematocrit level of 21% (37% -47%). These levels are found in patients with which condition?
Explanation
A. Thyroid disease: While some thyroid diseases may indirectly contribute to anemia, thyroid disease itself does not directly cause low hemoglobin and hematocrit.
B. Anemia: Low hemoglobin and hematocrit levels indicate anemia, which can be caused by various factors, including blood loss, iron deficiency, or chronic disease.
C. Acute bronchitis: Acute bronchitis typically affects respiratory function and does not directly cause a decrease in hemoglobin or hematocrit.
D. Hemochromatosis: Hemochromatosis is characterized by excess iron in the body, often resulting in elevated rather than decreased hemoglobin and hematocrit.
. The nurse is caring for the patient who is 1-day status post splenectomy. The patient complains of pain of a 3 on inspiration. What would be the most appropriate priority nursing intervention for this patient?
Explanation
A. Contact the surgeon to obtain orders for a nebulizer treatment from respiratory therapy. A nebulizer is typically not the initial intervention for mild post-operative pain or mild respiratory discomfort due to pain with inspiration.
B. Provide the patient with a heating pad alternated with a cold pack for incisional pain. While heat or cold therapy can help with pain, opioid pain management with encouragement to perform deep breathing exercises is more effective for post-splenectomy patients.
C. Medicate with opioids for pain and assist the patient to deep breathe, cough, and ambulate. Pain management combined with encouraging deep breathing, coughing, and early ambulation helps prevent post-operative complications like atelectasis and pneumonia, which are common after abdominal surgeries.
D. Contact the surgeon to request a chest x-ray and a laboratory draw for CBC with differential. This intervention might be necessary if there were signs of infection or other complications, but mild pain with inspiration on the first day post-op does not typically warrant imaging or labs.
What types of cells are present in Hodgkin's lymphoma?
Explanation
A. RBC's: Red blood cells (RBCs) are not indicative of Hodgkin’s lymphoma; they are involved in oxygen transport throughout the body and are not a specific marker for any lymphoma.
B. Bence-Jones Cells: Bence-Jones proteins are light chain proteins found in the urine of patients with multiple myeloma, not Hodgkin’s lymphoma.
C. Stem Cells: Stem cells are progenitor cells that can develop into various blood cell types but are not characteristic of Hodgkin’s lymphoma specifically. Reed-Sternberg cells, not stem cells, are the hallmark of this disease.
D. Reed-Sternberg Cell: Reed-Sternberg cells are large, abnormal B cells that are characteristic of Hodgkin’s lymphoma. Their presence in lymph node tissue is a key diagnostic feature of the disease.
The home care nurse is providing teaching to the family of a patient with multiple myeloma. Which nursing diagnosis should guide the nurse for this teaching?
Explanation
A. Ineffective airway clearance related to swelling of the lymph nodes: Multiple myeloma primarily affects bone marrow and bones rather than lymph nodes, so this diagnosis is less relevant.
B. Ineffective tissue perfusion related to vascular occlusion: Vascular occlusion is not a common complication of multiple myeloma, although hyperviscosity can occur, especially in advanced stages. However, the primary concern is bone integrity.
C. Risk for injury related to compromised bone integrity: Multiple myeloma weakens bones due to the presence of osteolytic lesions, increasing the risk for fractures. Teaching the family about measures to prevent injury is crucial.
D. Risk for deficit fluid volume related to a bleeding disorder: Multiple myeloma does not usually cause a primary bleeding disorder that would result in fluid volume deficit. Bone fractures and hypercalcemia are more immediate concerns.
A nurse is caring for an adolescent who is having a sickle cell crisis. Which of the following nursing actions should the nurse take?
Explanation
A. Initiate a 2 L/day fluid restriction: Hydration is crucial in sickle cell crisis to prevent further sickling and reduce blood viscosity. A fluid restriction would worsen the crisis.
B. Assist with administering a blood transfusion: Blood transfusions are commonly given during sickle cell crisis to manage anemia and reduce the concentration of sickled cells, which can improve oxygen delivery and relieve pain.
C. Withhold opioids to avoid dependence: Pain management, including opioids if needed, is essential during a sickle cell crisis. The risk of dependence is secondary to controlling acute pain.
D. Encourage exercise: Rest is recommended during a crisis to reduce oxygen demand and prevent further sickling. Exercise would increase oxygen needs, worsening the crisis.
A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first?
Explanation
A. Stop the transfusion: Stopping the transfusion is the priority action to prevent further exposure to the antigen causing the reaction.
B. Administer diphenhydramine: Administering diphenhydramine is an appropriate intervention for allergic reactions, but stopping the transfusion should be done first to halt the reaction source.
C. Obtain vital signs. Obtaining vital signs is important but should follow stopping the transfusion to address the immediate risk of reaction.
D. Notify the registered nurse: Notifying the registered nurse is necessary but comes after stopping the transfusion to immediately mitigate the reaction.
The nurse is assisting the patient with multiple myeloma in arranging a meal plan to lower the risk of complications from hypercalcemia. Which of the following would be the MOST IMPORTANT component of the patient's intake?
Explanation
A. The patient should increase intake of fluids. Increased fluid intake helps flush excess calcium from the kidneys, which is vital for patients with hypercalcemia, a common complication of multiple myeloma.
B. The patient should increase intake of fresh fruits. Fresh fruits can be healthy but do not directly reduce hypercalcemia risk. Fluid intake is more critical in preventing calcium build up.
C. The patient should decrease intake of red meat. While reducing red meat can be beneficial for overall health, it does not directly address hypercalcemia.
D. The patient should avoid alcoholic beverages. Avoiding alcohol is generally beneficial, but it is not specifically related to managing hypercalcemia in multiple myeloma.
The nurse is caring for a patient receiving treatment for a hemolytic reaction from a mismatched blood transfusion. The nurse understands that this the incompatible blood is causing what?
Explanation
A. Malformed RBCs: Malformed RBCs are not caused by a transfusion reaction; they are generally a result of bone marrow abnormalities or genetic conditions.
B. A deficiency in vitamin B12: Vitamin B12 deficiency causes megaloblastic anemia, not hemolysis. It is unrelated to transfusion reactions.
C. An abundance of immature RBCs: Immature RBCs, or reticulocytes, can increase as a compensatory response to anemia but are not a direct result of a transfusion reaction. The primary issue is RBC destruction.
D. Destruction of RBCs: A hemolytic reaction occurs when the immune system attacks incompatible red blood cells, leading to their destruction.
A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations?
Explanation
A. Jaw Pain: Jaw pain is not typically associated with a hemolytic transfusion reaction. It may be more relevant in cardiac issues or in rare cases of referred pain, but it is not an indicator of transfusion reaction.
B. Urticaria: Urticaria (hives) is associated with allergic reactions, not specifically with hemolytic reactions. Acute hemolytic reactions are characterized more by systemic symptoms like hypotension and fever.
C. Distended neck veins: Distended neck veins suggest fluid overload or cardiac issues but are not characteristic of an acute hemolytic reaction.
D. Hypotension: Hypotension is a common sign of an acute hemolytic transfusion reaction. This occurs when the immune system attacks transfused red blood cells, leading to hemolysis, which can cause shock and a drop-in blood pressure.
A nurse is assisting with the discharge of a child who has sickle cell anemia and is recovering from an acute sickle cell crisis. Which of the following instructions should the nurse reinforce with the child's parents?
Explanation
A. Have the child eat a high-protein diet. There is no specific requirement for a high-protein diet to manage sickle cell disease. Hydration is more critical in crisis prevention.
B. Monitor the child's temperature twice per day. While monitoring for infection is essential, this is not the most important discharge instruction to prevent crises.
C. Restrict outdoor play activity. While strenuous exercise should be avoided, activity restriction is unnecessary as long as the child stays hydrated and avoids extreme conditions.
D. Encourage the child to increase his fluid intake. Increased fluid intake helps prevent sickling by reducing blood viscosity, which is essential in preventing future crises.
A nurse is reinforcing teaching about pernicious anemia with a client following a total gastrectomy. Which of the following dietary supplements should the nurse include in the teaching as the treatment for pernicious anemia?
Explanation
A. Folate: Folate is important for red blood cell production but does not address the Vitamin B12 deficiency seen in pernicious anemia.
B. Vitamin C: Vitamin C does not impact pernicious anemia as it is not involved in Vitamin B12 absorption.
C. Vitamin B12: Pernicious anemia occurs due to a lack of intrinsic factor, which is necessary for Vitamin B12 absorption. After a total gastrectomy, intrinsic factor is no longer produced, requiring Vitamin B12 supplementation.
D. Iron: Iron deficiency anemia is different from pernicious anemia, which specifically requires Vitamin B12 supplementation.
The nurse is caring for a patient with stage IV Hodgkin disease. Where should the nurse expect to find enlarged lymph nodes during the assessment?
Explanation
A. Two areas of lymph nodes above and below the diaphragm: This describes stage III Hodgkin disease, where lymph node involvement occurs both above and below the diaphragm, but not necessarily in multiple organs.
B. Two or more areas on the same side of the diaphragm: This corresponds to stage II Hodgkin disease, which is limited to two or more lymph node regions on the same side of the diaphragm.
C. Localized in the cervical neck area only: Stage I Hodgkin disease typically involves a single lymph node region, often the cervical nodes, without generalized or extensive spread.
D. Generalized throughout the body within multiple organs: In stage IV Hodgkin disease, the cancer has spread beyond the lymph nodes to other organs and tissues, leading to generalized lymphadenopathy and potential organ involvement.
The nurse is reviewing laboratory values for a patient with thrombocytopenia associated with ITP. Which result would concern the nurse the most?
Explanation
A. Red blood cells (RBCs) 5.0 million/mm³ (F 4.2–5.4; M 4.7–6.1): This RBC count is within normal limits and does not indicate a concern related to thrombocytopenia.
B. Hemoglobin 14.5 g/100 mL (F 12–16; M 14–18): Hemoglobin is within normal limits and is not an immediate concern for a patient with ITP, as thrombocytopenia primarily affects platelets, not hemoglobin levels.
C. Platelets 50,000/mm³ (150,000–400,000): A platelet count of 50,000/mm³ is significantly below the normal range and poses a risk for bleeding, which is the primary concern in ITP (immune thrombocytopenic purpura).
D. White blood cells (WBCs) 7,400/mm³ (5,000–10,000): The WBC count is normal and not directly related to thrombocytopenia in ITP, which specifically affects platelets.
The nurse is preparing to assist the physician with a bone marrow biopsy. Which of the following interventions is most important for the nurse to carry out before the procedure?
Explanation
A. Explain the procedure to the patient’s family: While helpful, this is not as crucial as ensuring patient comfort and pain management during the procedure itself.
B. Observe the patient for bleeding: Observing for bleeding is important post-procedure rather than beforehand.
C. Drape the biopsy site: Draping is part of the procedure setup, but pain management is more critical for patient preparation.
D. Administer an analgesic to the patient: Administering an analgesic is essential to manage pain and discomfort during a bone marrow biopsy. This ensures the patient is as comfortable as possible.
The nurse is teaching the parent of a child with hemophilia. Which of the following statements by the parent demonstrates understanding about preventing bleeding episodes?
Explanation
A. "My son will have to grow a beard." Growing a beard is irrelevant to managing hemophilia and preventing bleeding.
B. "My son will have to avoid contact sports." Avoiding contact sports is essential for children with hemophilia to reduce the risk of trauma and bleeding episodes due to their clotting factor deficiency.
C. "My son will have to avoid fresh foods such as fruit in his diet." Fresh foods like fruits do not pose a bleeding risk for hemophilia; dietary restrictions are generally unnecessary in managing this condition.
D. "My son will always have to live near a major hospital."While proximity to a healthcare facility can be helpful in emergencies, this is not a requirement for managing hemophilia, nor does it directly prevent bleeding episodes.
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