While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?

Correct Answer: A

Rationale: When monitoring a client for the development of disseminated intravascular coagulation (DIC), it is important to assess key parameters that can indicate abnormal clotting and bleeding tendencies. The platelet count is essential as DIC can lead to thrombocytopenia (low platelet count). Prothrombin time (PT) and partial thromboplastin time (PTT) are coagulation tests that evaluate the extrinsic and intrinsic pathways of blood clotting, respectively. Prolongation of these times can indicate abnormal coagulation processes seen in DIC. Monitoring these parameters allows healthcare providers to assess and manage DIC promptly to prevent further complications.

Correct Answer: B

Rationale: The greatest likelihood of an acute hemolytic reaction occurs when there is mismatch in the ABO blood group system, specifically when the recipient's plasma contains antibodies against the donor's red blood cells. In this scenario, giving O-positive blood to an A-positive client presents the highest risk because the A-positive client has anti-B antibodies in their plasma, which can attack the B antigens present on the O-positive donor red blood cells. This mismatch can lead to rapid destruction of the transfused red blood cells, causing an acute hemolytic reaction. It is crucial to ensure ABO compatibility to prevent such life-threatening reactions during blood product transfusions.

Correct Answer: B

Rationale: When taking the blood pressure of a client with AIDS, it is important for the nurse to use barrier techniques to prevent the potential transmission of infection. This includes wearing gloves to protect against exposure to blood or other bodily fluids, using disposable blood pressure cuffs and stethoscopes, and ensuring proper hand hygiene before and after the procedure. Barrier techniques help minimize the risk of cross-contamination and protect both the healthcare provider and the client from potential infections.

Correct Answer: A

Rationale: Monitoring intake and output of fluids is essential for an elderly client who develops severe bone marrow depression from chemotherapy for prostate cancer. Bone marrow depression can result in decreased production of blood cells, including red blood cells, white blood cells, and platelets. Monitoring intake and output of fluids helps assess hydration status and kidney function. Decreased fluid intake or output may indicate kidney damage or dehydration, which are common concerns in clients with bone marrow depression. Therefore, it is crucial for the nurse to monitor the client's fluid balance closely to ensure optimal functioning of the kidneys and prevent complications related to bone marrow suppression.

Correct Answer: C

Rationale: Walking home in a cold rain can trigger a sickle cell crisis in individuals with sickle cell disease. Exposure to cold temperatures or getting wet can lead to vasoconstriction, causing the blood vessels to narrow and slow down blood flow. This reduced blood flow can increase the likelihood of sickle cells sticking together and blocking blood vessels, leading to pain and tissue damage characteristic of a sickle cell crisis. It is essential for individuals with sickle cell disease to avoid exposure to extreme temperatures, including cold rain, to prevent the onset of a crisis.