A patient reports increased fatigue, malaise, bleeding gums, and frequent "chills" to the nurse. What is the priority nursing
intervention?
A. Document assessment findings.
B. Notify the health care provider of the patient's symptoms.
C. Obtain vital signs and administer antipyretic medications.
D. Review laboratory analysis for signs and symptoms of bone marrow suppression.
D.
The nurse should initially review the patient's laboratory analysis for collective signs of pancytopenia related to the patient's reports of fatigue (anemia),
bleeding gums (thrombocytopenia), and chills (neutropenia). Laboratory data are needed before informing the physician and deciding whether to
administer an antibiotic. Obtaining blood cultures prior to antibiotic administration is an important intervention. Antipyretic medications may be prescribed
to treat the patient's symptoms ("chills").
The nurse is taking a history for an 80-year-old female patient who reports progressive fatigue, shortness of breath, and
headaches. What is the priority assessment question the nurse should ask?
A. "Can you tell me about your diet?"
B. "Have you been feeling depressed lately?"
C. "What medications do you routinely take?"
D. "Do you have a history of cardiovascular disease?"
A.
Rationale: All are possible questions to ask a patient regarding symptoms of fatigue, shortness of breath, and headaches. However, older patients are
more likely to experience signs and symptoms of anemia (fatigue, shortness of breath, headaches) related to diet and chronically bleeding GI lesions
(peptic ulcer disease).
A patient is transitioning from IV heparin therapy to oral warfarin. The nurse recognizes which laboratory finding that
indicates warfarin treatment efficacy?
A. Bleeding time of 5 minutes
B. Prothrombin time (PT) of 18 seconds
C. International normalized ratio (INR) of 2.5
D. Partial thromboplastin time (PTT) of 24.3 seconds
C.
Rationale: INR is a more accurate measure of anticoagulation therapy because of variations in PT values across different laboratories. The goal of
warfarin therapy is usually to maintain the patient's INR between 2.0 and 3.0 regardless of the actual PT in seconds.
A 27-year-old female with a history of sickle cell disease (SCD) comes to the ED with abdominal pain that is rated as a "9"
on a 0-to-10 scale. Physical assessment shows that she is grimacing and guarding her abdomen and has a fever of 103º
F, a pale yellow hard palate, and several very small ulcers on her lower extremities.
What is the priority problem that the nurse must immediately address?
A. Acute pain
B. Hyperthermia
C. Potential for infection
D. Decreased tissue perfusion
A.
The patient's pain must be controlled first and foremost. All other problems can be addressed after the acute pain is managed.
, Thirty minutes later, the patient is diagnosed with acute sickle cell crisis. She continues to have pain.
Which drugs does the nurse anticipate would be prescribed for pain control at this time? (Select all that apply.)
A. Meperidine IV push prn
B. Acetaminophen orally or rectally
C. Hydromorphone IV push scheduled doses
D. Morphine sulfate IV push scheduled doses
E. Morphine sulfate SR orally or IM scheduled doses
C, D
A patient in sickle cell crisis often starts with at least 48 hours of IV analgesia. Morphine and hydromorphone (Dilaudid) are given IV on a regular schedule,
or using a patient-controlled analgesia (PCA) pump. Once relief is obtained, the IV dose can be tapered and oral drugs may be given. PRN dosages
should be avoided because they do not provide adequate pain relief. IM injections should be avoided because absorption is impaired by poor perfusion
and sclerosed skin.
Three hours later, the patient is admitted to the acute medical care unit. Laboratory studies for the patient are ordered.
Which result does the nurse anticipate?
A. Hct 40%
B. HbS 90%
C. WBC 7000/mm3
D. Total bilirubin 0.5 mg/dL
B.
The HbS is reflective of a patient with sickle cell disease (SCD). Patients with SCD usually have low Hct, high WBC, and high total bilirubin. The other
values shown here are within normal limits.
The provider's orders include hydroxyurea (Droxia). Two hours later when the nurse administers the medication, the
patient asks about the purpose of this drug.
1. What is the appropriate nursing response?
2. What follow-up laboratory value would the nurse monitor while the patient is taking hydroxyurea?
1. Hydroxyurea has been successfully used to reduce the number of sickling and pain episodes.
2. CBC - Hydroxyurea suppresses bone marrow function, so it is important to monitor complete blood counts.
Four days later, the patient is preparing for discharge.
Which teaching points would the nurse provide to the patient and her family? (Select all that apply.)
A. Be sure to get a flu shot annually.
B. Drink at least 3 to 4 liters of fluid daily.
C. Avoid temperature extremes of hot or cold.
D. Alcoholic beverages may be consumed moderately.
E. Engage in mild low-impact exercise three times a week when not in crisis.
A, B, E
Hydration helps decrease the duration of pain episodes. Flu shots are important because the patient is at risk for infections due to decreased spleen
function. Low-impact exercise is recommended, but patients should avoid strenuous exercise. Alcohol should be avoided.
intervention?
A. Document assessment findings.
B. Notify the health care provider of the patient's symptoms.
C. Obtain vital signs and administer antipyretic medications.
D. Review laboratory analysis for signs and symptoms of bone marrow suppression.
D.
The nurse should initially review the patient's laboratory analysis for collective signs of pancytopenia related to the patient's reports of fatigue (anemia),
bleeding gums (thrombocytopenia), and chills (neutropenia). Laboratory data are needed before informing the physician and deciding whether to
administer an antibiotic. Obtaining blood cultures prior to antibiotic administration is an important intervention. Antipyretic medications may be prescribed
to treat the patient's symptoms ("chills").
The nurse is taking a history for an 80-year-old female patient who reports progressive fatigue, shortness of breath, and
headaches. What is the priority assessment question the nurse should ask?
A. "Can you tell me about your diet?"
B. "Have you been feeling depressed lately?"
C. "What medications do you routinely take?"
D. "Do you have a history of cardiovascular disease?"
A.
Rationale: All are possible questions to ask a patient regarding symptoms of fatigue, shortness of breath, and headaches. However, older patients are
more likely to experience signs and symptoms of anemia (fatigue, shortness of breath, headaches) related to diet and chronically bleeding GI lesions
(peptic ulcer disease).
A patient is transitioning from IV heparin therapy to oral warfarin. The nurse recognizes which laboratory finding that
indicates warfarin treatment efficacy?
A. Bleeding time of 5 minutes
B. Prothrombin time (PT) of 18 seconds
C. International normalized ratio (INR) of 2.5
D. Partial thromboplastin time (PTT) of 24.3 seconds
C.
Rationale: INR is a more accurate measure of anticoagulation therapy because of variations in PT values across different laboratories. The goal of
warfarin therapy is usually to maintain the patient's INR between 2.0 and 3.0 regardless of the actual PT in seconds.
A 27-year-old female with a history of sickle cell disease (SCD) comes to the ED with abdominal pain that is rated as a "9"
on a 0-to-10 scale. Physical assessment shows that she is grimacing and guarding her abdomen and has a fever of 103º
F, a pale yellow hard palate, and several very small ulcers on her lower extremities.
What is the priority problem that the nurse must immediately address?
A. Acute pain
B. Hyperthermia
C. Potential for infection
D. Decreased tissue perfusion
A.
The patient's pain must be controlled first and foremost. All other problems can be addressed after the acute pain is managed.
, Thirty minutes later, the patient is diagnosed with acute sickle cell crisis. She continues to have pain.
Which drugs does the nurse anticipate would be prescribed for pain control at this time? (Select all that apply.)
A. Meperidine IV push prn
B. Acetaminophen orally or rectally
C. Hydromorphone IV push scheduled doses
D. Morphine sulfate IV push scheduled doses
E. Morphine sulfate SR orally or IM scheduled doses
C, D
A patient in sickle cell crisis often starts with at least 48 hours of IV analgesia. Morphine and hydromorphone (Dilaudid) are given IV on a regular schedule,
or using a patient-controlled analgesia (PCA) pump. Once relief is obtained, the IV dose can be tapered and oral drugs may be given. PRN dosages
should be avoided because they do not provide adequate pain relief. IM injections should be avoided because absorption is impaired by poor perfusion
and sclerosed skin.
Three hours later, the patient is admitted to the acute medical care unit. Laboratory studies for the patient are ordered.
Which result does the nurse anticipate?
A. Hct 40%
B. HbS 90%
C. WBC 7000/mm3
D. Total bilirubin 0.5 mg/dL
B.
The HbS is reflective of a patient with sickle cell disease (SCD). Patients with SCD usually have low Hct, high WBC, and high total bilirubin. The other
values shown here are within normal limits.
The provider's orders include hydroxyurea (Droxia). Two hours later when the nurse administers the medication, the
patient asks about the purpose of this drug.
1. What is the appropriate nursing response?
2. What follow-up laboratory value would the nurse monitor while the patient is taking hydroxyurea?
1. Hydroxyurea has been successfully used to reduce the number of sickling and pain episodes.
2. CBC - Hydroxyurea suppresses bone marrow function, so it is important to monitor complete blood counts.
Four days later, the patient is preparing for discharge.
Which teaching points would the nurse provide to the patient and her family? (Select all that apply.)
A. Be sure to get a flu shot annually.
B. Drink at least 3 to 4 liters of fluid daily.
C. Avoid temperature extremes of hot or cold.
D. Alcoholic beverages may be consumed moderately.
E. Engage in mild low-impact exercise three times a week when not in crisis.
A, B, E
Hydration helps decrease the duration of pain episodes. Flu shots are important because the patient is at risk for infections due to decreased spleen
function. Low-impact exercise is recommended, but patients should avoid strenuous exercise. Alcohol should be avoided.
