ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 32 Questions
Question 1 of 5
A nurse at a blood donation clinic has completed the collection of blood from a woman. The woman states that she feels lightheaded and she appears visibly pale. What is the nurses most appropriate action?
Correct Answer: A
Rationale: A donor who appears pale or complains of faintness should immediately lie down or sit with the head lowered below the knees. He or she should be observed for another 30 minutes. There is no immediate need for a physicians care. Supplementary oxygen may be beneficial, but may take too much time to facilitate before a syncopal episode. Repositioning must precede assessment of vital signs.
Question 2 of 5
The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take?
Correct Answer: B
Rationale: Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions. The nurse should discontinue the transfusion immediately, monitor the patients vital signs, and notify the physician. The blood container and tubing should be sent to the blood bank. A blood and urine specimen may be needed if a transfusion reaction or a bacterial infection is suspected. The patients IV access should not be removed.
Question 3 of 5
An individual has accidentally cut his hand, immediately initiating the process of hemostasis. Following vasoconstriction, what event in the process of hemostasis will take place?
Correct Answer: B
Rationale: Following vasoconstriction, circulating platelets aggregate at the site and adhere to the vessel and to one another, forming an unstable hemostatic plug. Events involved in the clotting cascade take place subsequent to this initial platelet action.
Question 4 of 5
A patient is receiving a blood transfusion and complains of a new onset of slight dyspnea. The nurses rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurses most appropriate action?
Correct Answer: A
Rationale: The patient is showing early signs of hypervolemia; the nurse should slow the infusion rate and assess the patient closely for any signs of exacerbation. At this stage, discontinuing the transfusion is not necessary. A bolus would worsen the patients fluid overload.
Question 5 of 5
A nurse is caring for a patient who undergoing preliminary testing for a hematologic disorder. What sign or symptom most likely suggests a potential hematologic disorder?
Correct Answer: D
Rationale: The most common indicator of hematologic disease is extreme fatigue. This is more common than changes in LOC, infections, or anaphylaxis.