Exam (elaborations) ADULT 1

A client suffers a leg wound which causes minor blood loss. As a result of bleeding, the process of primary hemostasis is activated. What will occur during this process? - ANSWER Severed blood vessels constrict The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take? - ANSWER Stop the transfusion immediately A client is being treated for the effects of a longstanding vitamin B12 deficiency. What aspect of the client's health history would most likely predispose her to this deficiency? - ANSWER The client is a vegan. A client's diagnosis of atrial fibrillation has prompted the primary provider to prescribe warfarin. When assessing the therapeutic response to this medication, what is the nurse's most appropriate action? - ANSWER Review the client's international normalized ratio (INR) A client's low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should the nurse perform? - ANSWER Assess the client's vital signs to establish baselines A client on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurse's most appropriate action? - ANSWER Discontinue the remainder of the PRBC transfusion and inform the health care provider A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction? - ANSWER The donor blood was incompatible with that of the client. The nurse is preparing to administer a unit of platelets to an adult client. When administering this blood product, which of the following actions should the nurse perform? - ANSWER Administer the platelets as rapidly as the client can tolerate A client newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment, the client asks the nurse to explain the disease. What potential etiology should the nurse explain to this client? - ANSWER Decreased production of platelets A nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education? - ANSWER Iron will cause the stools to darken in color A client with kidney injury has decreased erythropoietin production. Upon analysis of the client's complete blood count, the nurse will expect which of the following results? - ANSWER A decreased hemoglobin and hematocrit