which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia
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Nursing Elites

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ATI Perfusion Quizlet

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

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. A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to

Correct answer: D

Rationale: The patient's symptoms, back pain, and difficulty breathing after the transfusion indicate a possible acute hemolytic reaction, a severe transfusion reaction. The priority action in this situation is to discontinue the transfusion immediately to prevent further complications. Infusing normal saline helps maintain the patient's intravascular volume and prevent renal damage. Administering oxygen or obtaining a urine specimen is not the most urgent action and could delay essential treatment. Notifying the healthcare provider is important but should come after ensuring the patient's safety by stopping the blood transfusion.

3. Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate?

Correct answer: A

Rationale: It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the health care provider about this.

4. A patient's complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding?

Correct answer: B

Rationale: The correct answer is B: "Do you have any history of lung disease?" The elevated hemoglobin and hematocrit levels suggest polycythemia, which can be seen in conditions like chronic obstructive pulmonary disease (COPD). Option A is less relevant as weight loss is not typically associated with these blood count findings. Option C is more indicative of gastrointestinal bleeding rather than a respiratory issue. Option D focuses on dietary factors, which are less likely to cause such significant elevations in hemoglobin and hematocrit levels as seen in this case.

5. Which task for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?

Correct answer: C

Rationale: The correct answer is C because administering subcutaneous medications falls within the education and scope of practice of an LPN/LVN. Assessing the patient for signs and symptoms of infection, teaching the patient, and developing a discharge plan are tasks that require an RN level of education and scope of practice. LPN/LVNs can assist in patient care, but tasks that involve assessment, teaching, and care planning are typically the responsibility of an RN.

Similar Questions

After a patient with pancytopenia undergoes a bone marrow aspiration from the left posterior iliac crest, which action would be important for the nurse to take?
Which menu choice indicates that the patient understands the nurse's teaching about recommended dietary choices for iron-deficiency anemia?
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)?
Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the healthcare provider?
A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test?

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