ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 40 : Care of Patients with Hematologic Problems Questions
Question 1 of 5
A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important?
Correct Answer: B
Rationale: This client has a hemolytic transfusion reaction, most commonly caused by blood type or Rh incompatibility. The nurse should double-check all identifying information for both the client and blood type to confirm the error. Documentation occurs after the client is stable. Bedrest may not be needed, and allergies to medications or environmental items are not related.
Question 2 of 5
A client has thrombocytopenia. What client statement indicates the client understands self-management of this condition?
Correct Answer: C
Rationale: The client should be taught to apply ice to areas of minor trauma to reduce bleeding risk. Flossing is not recommended due to the risk of gum bleeding. Hard foods should be avoided to prevent injury, and while nonslip socks promote safety, they do not directly address thrombocytopenia management.
Question 3 of 5
A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the client?
Correct Answer: C
Rationale: During a sickle cell crisis, the tissue distal to the occlusion has decreased blood flow and ischemia, leading to pain. Keeping the legs warm helps improve comfort due to decreased blood flow causing coolness. Elevation or elastic bandages may further reduce perfusion, and ice packs are not indicated.
Question 4 of 5
A client admitted for sickle cell crisis is distraught after learning her child also has the disease. What response by the nurse is best?
Correct Answer: B
Rationale: The best response is for the nurse to offer self, a therapeutic communication technique that uses presence to provide emotional support. Assigning blame or focusing on treatments does not address the client's emotional distress, and while offering help is supportive, staying with the client is the most immediate and effective response.
Question 5 of 5
A client with sickle cell disease (SCD) takes hydroxyurea (Droxia). The client presents to the clinic reporting an increase in fatigue. What laboratory result should the nurse report immediately?
Correct Answer: D
Rationale: Although individuals with SCD often have elevated white blood cell counts, an extreme elevation like 38,000/mm3 could indicate leukemia, a serious complication of hydroxyurea, or a severe infection, both critical in SCD patients. Hematocrit and hemoglobin levels are typically low in SCD, and the potassium level, while slightly low, is less urgent.