Nursing Elites

1. A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take?

• A. Give the PRN diphenhydramine
• B. Send a urine specimen to the laboratory
• C. Administer PRN acetaminophen (Tylenol)
• D. Draw blood for a new type and crossmatch

Correct answer: C

Rationale: The patient’s clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered.

2. The nurse is caring for a patient who is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching?

• A. Check frequently for swollen lymph nodes.
• B. Watch for excessive bleeding or bruising.
• C. Take iron supplements to prevent anemia.
• D. Wash hands regularly and avoid individuals who are ill.

Correct answer: D

Rationale: The correct answer is D: 'Wash hands regularly and avoid individuals who are ill.' After a splenectomy, the patient is at an increased risk of infection, particularly from gram-positive bacteria. Proper hand hygiene and avoiding contact with sick individuals are crucial to prevent infections. Choices A, B, and C are incorrect because checking for swollen lymph nodes, watching for excessive bleeding or bruising, and taking iron supplements are not specifically related to the increased infection risk post-splenectomy.

3. A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the healthcare provider before obtaining and administering platelets?

• A. Platelet count is 42,000/µL
• B. Petechiae are present on the chest
• C. Blood pressure (BP) is 94/56 mm Hg
• D. Blood is oozing from the venipuncture site

Correct answer: A

Rationale: The correct answer is A. Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/µL unless the patient is actively bleeding. In this case, with a platelet count of 42,000/µL, the count is not critically low, and the patient is not actively bleeding. Therefore, the nurse should consult with the healthcare provider before giving the transfusion. Choices B, C, and D are incorrect because the presence of petechiae, low blood pressure, and oozing from the venipuncture site are common findings in patients with ITP and do not necessarily require immediate consultation before administering a platelet transfusion.

4. An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/µL during chemotherapy is to

• A. check all stools for occult blood
• B. encourage fluids to 3000 mL/day
• C. provide oral hygiene every 2 hours
• D. check the temperature every 4 hours

Correct answer: A

Rationale: The correct answer is to check all stools for occult blood. With a platelet count of 18,000/µL, the patient is at a high risk of spontaneous bleeding. Checking stools for occult blood can help detect any internal bleeding early. Encouraging fluids and providing oral hygiene are important interventions in general, but in this case, monitoring for bleeding takes precedence. Checking the temperature every 4 hours is not directly related to the patient's current condition and platelet count.

5. The nurse is reviewing laboratory results and notes a patient's activated partial thromboplastin time (aPTT) level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication?

• A. Aspirin
• B. Heparin
• C. Warfarin
• D. Erythropoietin

Correct answer: B

Rationale: The correct answer is B: Heparin. An activated partial thromboplastin time (aPTT) level of 28 seconds indicates a prolonged time, which is associated with heparin administration. Heparin is an anticoagulant medication that affects the intrinsic pathway of the coagulation cascade, leading to an increased aPTT. Aspirin (choice A) affects platelet aggregation and does not directly impact aPTT. Warfarin (choice C) affects the extrinsic pathway of the coagulation cascade and is monitored using the international normalized ratio (INR), not aPTT. Erythropoietin (choice D) is not related to coagulation parameters.

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