Lab Results
A nurse in a clinic is caring for a client who has suspected anemia. Which of the following laboratory test results should the nurse expect?
A. Iron 90 mcg/dL
B. RBC 6.5 million/uL
C. WBC 4,800 mm cubed
D. Hgb 10 g/dL
D. Hgb 10 g/dL
The doctor has ordered blood to be transfused. The nurse is aware that blood should not hang longer than four hours to prevent?
Deterioration and bacterial growth.
The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100*F orally. The nurse reports the finding to the RN and anticipates that which action will take place?
A. The transfusion will begin as prescribed
B. The transfusion will begin after the administration of an antihistamine
C. The transfusion will begin after the administration of 650mg of acetaminophen
D. The blood will be held, and the HCP will be notified.
D. The blood will be held, and the HCP will be notified.
Most common
Shaking/chills
Tachycardia/elevated temperature
Febrile Reaction
Stop infusion and notify HCP. Acetaminophen may be ordered. May continue infusion per HCP order once patient more comfortable.
Bleeding caused by thrombocytopenia.
Platelets
A client presents to the clinic with the following symptoms: weakness, jaundice, confusion, and dizziness. After assessing your client, what type of anemia would you suspect your client to have?
Hemolytic anemia
May be congenital/toxic cause. Causes destruction of RBCs, which can cause client to present with jaundice.
The nurse teaches a patient about vaccines. The nurse would evaluate the patient as understanding the presented information if the patient states that a vaccine provides which of these types of immunity?
A. Naturally acquired passive immunity
B. Artificially acquired passive immunity
C. Naturally acquired active immunity
D. Artificially acquired active immunity
D. Artificially acquired active immunity
A nurse is caring for a client who is receiving warfarin for anticoagulation therapy. Which of the following laboratory test results indicates to the nurse that the client needs an increase in the dosage?
A. aPTT 38 seconds
B. INR 1.1
C. PT 22 seconds
D. D-dimer negative
B. INR 1.1
What blood type is the universal donor?
A. O+
B. O-
C. A+
D. A-
B. O-
O- blood cells have no A, B, or Rh antigens and can be safely given to people of any blood group.
A nurse is monitoring a patient during a blood transfusion. After the blood has been hanging for 30 minutes, the patient's temperature rises from 98.6*F at baseline to 101.0*F. The patient also experiences severe chills. Which action should the nurse take FIRST?
a. Document the vital signs in the medical record
B. Administer acetaminophen for the fever
C. Notify the HCP of the change
D. Stop the transfusion and hang normal saline.
D. Stop the transfusion and hang normal saline.
Back pain
chest pain
chills/fever
SOB
N/V
Hemolytic Reaction
Deadliest reaction/destruction of RBCs
STOP the infusion at FIRST sign of reaction; stay with patient; Emergency, call for assistance to notify supervisor and HCP. Change tubing and infuse normal saline
Hypovolemia caused by hypoalbuminemia.
Albumin
In teaching a parent of a client with hemophilia A about hemarthrosis it is important to include all of the following except:
A. "Bleeding into your muscles and joints don't usually occur unless you have an injury."
B. "Hemarthrosis over time can cause joint deformities, especially in the elbows, knees and ankles."
C. "You can help control bleeding by immobilization, elevation and application of ice/cold packs for 24-48 hours."
D. "Monitor for joint pain and immobilize affected extremity if joint pain occurs."
A. "Bleeding into your muscles and joints don't usually occur unless you have an injury."
The nurse is assisting with data collection on a patient. Which of the following past surgeries found in the patient's history would alert the nurse to possible immune system dysfunction when planning care? Select all that apply
A. Appendectomy
B. Parathyroidectomy
C. Pneumonectomy
D. Splenectomy
E. Thyroidectomy
F. Thymectomy
D. Splenectomy
F. Thymectomy
The therapeutic range for someone on warfarin is...
2.0-3.0 for patient on warfarin
3.0-4.5 for patient with recurrent problems
What blood type is considered the universal recipient?
AB+ is universal blood type because they can receive blood from all blood types.
A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse plan to take if an allergic transfusion reaction is suspected? Select all that apply
A. Stop the transfusion
B. Monitor for hypertension
C. Maintain an IV infusion with 0.9% sodium chloride
D. Position the client in an upright position with the feet lower than the heart.
E. Administer diphenhydramine
A. Stop the transfusion
C. Maintain an IV infusion with 0.9% sodium chloride
E. Administer diphenhydramine
Hive-like rash
may be a fever
Urticarial Reaction
Stop transfusion, notify HCP and expect patient to be given an antihistamine.
Severe anemia or blood loss
Packed RBCs
What education should you give a client when prescribed ferrous sulfate (Iron)?
Take with Vitamin C. Vitamin C helps your body absorb iron.
Take on an empty stomach: 2 hours after meal or one hour before meals. Helps absorption of iron.
Do not take with antacids. They can interfere with absorption.
A nurse is caring for a client who has a WBC count of 20,000/mm3. The nurse should conclude that the client has which of the following?
A. Neutropenia
B. Leukocytosis
C. Left Shift
D. Leukopenia
B. Leukocytosis
What are the normal lab values of Hgb for a male/female?
Male: 13.2-17.3 g/100mL
Female: 11.7-15.5 g/100mL
The nurse is caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item?
A. Vital Signs
B. Skin color
C. Oxygen saturation
D. Latest hematocrit level
A. Vital Signs
A nurse is reinforcing preoperative teaching for a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse include?
a. "You should make an appointment to donate blood 8 weeks prior to the surgery."
B. "If you need an autologous transfusion, the blood your brother donates can be used."
C. "You can donate blood each week if your hemoglobin is stable."
D. "Any unused blood that is donated can be used for other clients."
C. "You can donate blood each week if your hemoglobin is stable."
Severe GI cramping
vomiting
uncontrollable diarrhea
respiratory/cardiovascular collapse
Anaphylactic reaction
Stop transfusion; stay with patient; use emergency call system; CPR, steroids, epi
Bleeding caused by specific missing clotting factors
Cryoprecipitates
Signs and symptoms of DIC?
Ecchymosis, petechiae, bleeding from puncture sites (IV, IM), skin tears, GI bleeding and painful joints.
Protection acquired by giving a person an injection or transfusion of antibodies made by someone else is considered?
Artificially acquired passive immunity
What is the normal WBC count and platelet count?
WBC 4,500-11,000
Platelets: 150,000-450,000
Which of these clients is/are most likely to develop fluid (circulatory) overload? Select all that apply
1. A premature infant
2. A 101-year-old man
3. A client with heart failure
4. A client with diabetes mellitus
5. A client receiving renal dialysis
6. A 29-year old client with pneumonia.
1. A premature infant
2. A 101-year-old man
3. A client with heart failure
5. A client receiving renal dialysis
A nurse is assisting the charge nurse with the administration of a blood transfusion to an older adult client. Which of the following actions by the nurse indicates an understanding of the procedure?
A. Ensures that the client has an 18 gauge IV catheter.
B. Verifies blood compatibility and expiration date of blood with assistive personnel.
C. Ensures the administration of dextrose 5% in 0.9% sodium chloride IV with the infusion.
D. Obtains vital signs every 15 min. throughout the procedure.
D. Obtains vital signs every 15 min. throughout the procedure.
Use a 20 gauge IV in an older adult. Check the older adults vital signs every 15 min throughout the infusion to allow for early detection of fluid overload or other transfusion reactions.
Chest pain
cough
frothy sputum
distended neck veins
crackles/wheezes
increased heart rate
Circulatory Overload
Stop the transfusion; notify HCP; Anticipate administration of diuretics; may re-start transfusion later but at a slower rate. See Gerontological issues pg. 495.
Provides clotting factors for bleeding disorders; occasionally used for volume replacement; DIC (disseminated intravascular coagulation).
Fresh frozen plasma
What are some priority nursing diagnosis for a patient with leukemia?
Risk for Infection
Risk for Bleeding
Activity intolerance/risk for injury
What are the functions/locations of the following classes of Antibodies?
IgG
IgA
IgM
IgD
IgE
IgG: blood, extracellular fluid, lymph (provides long-term immunity after a vaccination of illness recovery. Crosses placenta to provide passive immunity in newborns.
IgA: External secretions (Found in secretions of all mucous membranes. Provides passive immunity for breastfed infants).
IgM: Blood, lymph (Produced first during an infection (IgG production follows).
IgD: B Cells (Antigen-specific receptors on B lymphocytes.
IgE: Mast/basophils (Important in allergic reactions. Mast cells release histamine).