ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 40 Questions
Question 1 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.
Question 2 of 5
A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medications, what action by the nurse is best?
Correct Answer: A
Rationale: Clients with sickle cell crisis often have severe pain that is managed with up to 48 hours of IV opioid analgesics. Even if the client is addicted and drug seeking, he or she is still in extreme pain. If the client can receive another dose of medication, the nurse should provide it. The other options are judgmental and do not address the client's pain. Giving placebos is unethical.
Question 3 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 4 of 5
The nurse instructor is best?
Correct Answer: D
Rationale: Graft versus host disease is an autoimmune-type process in which the donor cells recognize the client's cells as foreign and begin attacking them. The other answers are not accurate.
Question 5 of 5
A nurse is preparing to administer a blood transfusion to an older adult. Understanding age-related changes, what alterations to the usual protocol are necessary for the nurse to implement? (Select all that apply.)
Correct Answer: A,B
Rationale: Older adults require frequent vital sign monitoring (every 15 minutes) due to subtle signs of transfusion reactions and holding other IV fluids to prevent fluid overload. Premedication and prolonged transfusion times are not standard alterations.