Nursing Elites

1. Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia?

• A. Potential complication: seizures
• B. Potential complication: infection
• C. Potential complication: neurogenic shock
• D. Potential complication: pulmonary edema

Correct answer: B

Rationale: The correct answer is B: Potential complication: infection. Patients with idiopathic aplastic anemia have pancytopenia, which puts them at a high risk for infections due to decreased production of all blood cells (red blood cells, white blood cells, and platelets). Infection is a significant concern in these patients. Choices A, C, and D are incorrect because seizures, neurogenic shock, and pulmonary edema are not typically associated with idiopathic aplastic anemia. While seizures can occur in some conditions that affect the brain, neurogenic shock is related to spinal cord injury, and pulmonary edema is more commonly seen in conditions like heart failure.

2. The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care?

• A. Avoid intramuscular injections.
• B. Encourage increased oral fluids.
• C. Check temperature every 4 hours.
• D. Increase intake of iron-rich foods.

Correct answer: A

Rationale: The correct action to include in the plan of care for a thrombocytopenic patient is to avoid intramuscular injections. Thrombocytopenia is a condition characterized by a decreased number of platelets, which are essential for blood clotting. Intramuscular injections can pose a risk of bleeding in patients with low platelet counts. Encouraging increased oral fluids (choice B) is beneficial for hydration but does not directly address the risk of bleeding associated with thrombocytopenia. Checking temperature every 4 hours (choice C) is important for monitoring infection but does not specifically address the risk of bleeding. Increasing intake of iron-rich foods (choice D) is more related to addressing anemia, not the primary concern of bleeding in thrombocytopenia.

3. The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)?

• A. Verify the patient identification (ID) according to hospital policy
• B. Obtain the temperature, blood pressure, and pulse before the transfusion
• C. Double-check the product numbers on the PRBCs with the patient ID band
• D. Monitor the patient for shortness of breath or chest pain during the transfusion

Correct answer: B

Rationale: The correct answer is B. Unlicensed assistive personnel (UAP) can obtain the temperature, blood pressure, and pulse before a transfusion as their education includes measurement of vital signs. UAP would then report the vital signs to the registered nurse (RN). Option A is typically a nursing responsibility to ensure patient safety and avoid errors in patient identification. Option C involves cross-checking important details and ensuring accuracy, which is usually performed by nursing staff to prevent errors. Option D requires monitoring for potential adverse reactions during the transfusion, which is a nursing responsibility due to the need for assessment and intervention in case of complications.

4. A patient who has 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 scenario, the platelet count of 42,000/µL is not significantly low to warrant a platelet transfusion without active bleeding. Consulting with the healthcare provider is essential before giving the transfusion to ensure the appropriateness of the treatment. Choices B, C, and D are not directly related to the need for consulting before a platelet transfusion. Petechiae, low blood pressure, and oozing from the venipuncture site are common findings in patients with ITP and may not necessarily contraindicate a platelet transfusion at this platelet count.

5. Which menu choice indicates that the patient understands the nurse's teaching about recommended dietary choices for iron-deficiency anemia?

• A. Omelet and whole wheat toast
• B. Cantaloupe and cottage cheese
• C. Strawberry and banana fruit plate
• D. Cornmeal muffin and orange juice

Correct answer: D

Rationale: The correct answer is D: "Cornmeal muffin and orange juice." Cornmeal muffin is a good source of iron, which is beneficial for individuals with iron-deficiency anemia. Orange juice is high in vitamin C, which aids in iron absorption. Choices A, B, and C do not specifically address the need for iron-rich foods, making them less suitable for someone with iron-deficiency anemia. Omelet and whole wheat toast (Choice A) may provide some iron but are not as focused on addressing the specific deficiency. Cantaloupe and cottage cheese (Choice B) and strawberry and banana fruit plate (Choice C) are more general fruit choices and do not emphasize iron-rich options.

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