Chapter 75: Management of Clients with Hematologic Disorders Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 75: Management of Clients with Hematologic Disorders

MULTIPLE CHOICE

1. The nurse assessing a female client with a hemoglobin level of 11 g/dl would expect the client to report

a.

chronic fatigue and activity intolerance.

b.

no significant manifestations.

c.

shortness of breath, worse on exertion.

d.

tachycardia and palpitations.

ANS: B

Clients with mild anemia (hemoglobin level of 10 to 12 g/dl) are usually asymptomatic.

DIF: Comprehension/Understanding REF: p. 2005 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

2. While performing an admission assessment on a moderately anemic client, the nurse would expect to find a history of

a.

blurred vision.

b.

cardiac palpitations.

c.

increased appetite.

d.

warm, flushing sensations.

ANS: B

Clients with moderate anemia may suffer from dyspnea, palpitations, diaphoresis with exertion, and chronic fatigue.

DIF: Comprehension/Understanding REF: p. 2005 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

3. The nurse points out that nursing management of all individuals with anemia is primarily directed toward

a.

genetic counseling.

b.

identifying complications.

c.

managing manifestations.

d.

rehabilitative measures.

ANS: C

The goals of care for clients with anemia include (1) alleviating or controlling the causes, (2) relieving the manifestations, and (3) preventing complications.

DIF: Comprehension/Understanding REF: p. 2009 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

4. The statement about dietary iron made by a client with iron deficiency anemia that indicates understanding of the dietary concepts is I

a.

know that dairy products are the best source of iron.

b.

know that iron from animal sources is not absorbed well.

c.

should be able to change my diet so that I can get sufficient iron.

d.

will not be able to obtain enough iron by just increasing my dietary intake.

ANS: C

The amount of iron normally absorbed daily is sufficient for meeting the needs of women past the childbearing age and healthy men, but it does not meet the greater needs of menstruating and pregnant women, adolescents, children, and infants.

DIF: Evaluation/Evaluating REF: p. 2017 OBJ: Evaluation

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

5. The nurse would instruct an individual worried about developing iron deficiency anemia to avoid

a.

citrus fruits.

b.

leafy green vegetables.

c.

poultry.

d.

tea.

ANS: D

Tannates (in tea and coffee), carbonates, the chelating agent ethylenediaminetetraacetic acid (EDTA), and the medicinal antacid magnesium trisilicate all hinder non-heme iron absorption.

DIF: Application/Applying REF: p. 2017 OBJ: Intervention

MSC: Health Promotion Prevention and/or Early Detection of Health Problems-Disease Prevention

6. A nurse providing wellness seminars plans which of the following primary prevention activities related to sickle cell disease?

a.

Have a sick day management tip sheet for those with SCD.

b.

Offer information on genetic counseling for SSD.

c.

Plan to have a list of community resources for the families of people with SCD.

d.

Provide a list of day care providers willing to care for children with SCD.

ANS: B

Primary prevention aims to prevent disease and illness before it occurs. Having information available on genetic counseling would allow those who are at risk (African Americans mainly, but also includes those of Mediterranean, Middle Eastern, or East Indian descent) to assess their risks of having children born with SCD before they become pregnant. Sick day management tips, community resources, and day care providers would be for tertiary prevention.

DIF: Analysis/Analyzing REF: p. 2025 OBJ: Intervention

MSC: Health Promotion Prevention and/or Early Detection of Health Problems-Disease Prevention

7. A nurse is conducting a wellness seminar on healthy eating and prevention of iron deficiency anemia. The food the nurse would describe as being high in iron is

a.

citrus fruits.

b.

grains.

c.

green leafy vegetables.

d.

milk products.

ANS: C

Encourage foods cooked in iron pots and ingestion of foods such as liver (the richest source), oysters, lean meats, kidney beans, whole wheat bread, kale, spinach, egg yolk, turnip tops, beet greens, carrots, apricots, and raisins.

DIF: Application/Applying REF: p. 2036 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

8. A nurse is assessing a 10-year old child with severe sickle cell disease. The mother states the child used to love school but now wont go and wont play with any friends. The nurse notes the child is very thin with an oddly-shaped head and has significant ptosis. Which nursing diagnosis best fits this client?

a.

Altered family coping related to effects of disease on family

b.

Anxiety related to fear of the unknown and social stressors

c.

Readiness for Enhance Self Care related to disease and treatment

d.

Social Isolation related to body image changes

ANS: D

The child is isolating him/herself probably because of the unanticipated body image changes that have accompanied frequent bouts of SCD crisis. Anxiety might be the real problem, but without any further information Social Isolation is more appropriate.

DIF: Application/Applying REF: p. 2024 OBJ: Diagnosis

MSC: Psychosocial Integrity Coping and Adaptation-Unexpected Body Image Changes

9. To determine if the client has a risk factor related to iron deficiency anemia, the nurse could ask, Has the client had a

a.

blood transfusion recently?

b.

cardiac catheterization?

c.

operation involving the stomach?

d.

pregnancy terminated within the past 6 months?

ANS: C

Malabsorption of iron may result from alterations in the mucosa of the duodenum and proximal jejunum, gastrectomy, or removal of the proximal small bowel, resulting in iron deficiency anemia.

DIF: Application/Applying REF: p. 2017 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems

10. The nurse explains that the medication essential for a client with pernicious anemia is

a.

ferritin.

b.

ferrous gluconate.

c.

vitamin B12.

d.

vitamin K.

ANS: C

Clients with pernicious anemia need both immediate care and lifelong therapy with maintenance vitamin B12.

DIF: Comprehension/Understanding REF: p. 2020 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Expected Effects/Outcomes

11. The nurse informs a client suspected of having pernicious anemia that the lab study that will be helpful in the diagnosis is

a.

clotting studies.

b.

endoscopy.

c.

hemoglobin levels.

d.

Schilling test.

ANS: D

The Schilling test measures the absorption of orally administered radioactive vitamin B12 (tagged with cobalt 60) before and after parenteral administration of intrinsic factor. This procedure detects lack of intrinsic factor and is the definitive test for pernicious anemia.

DIF: Comprehension/Understanding REF: pp. 2019-2020

OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Diagnostic Tests

12. The nurse is aware that the situation that would warrant administration of iron supplements to a client with pernicious anemia is

a.

poor appetite.

b.

increase in the total erythrocyte count in the peripheral circulation.

c.

discrepancy between hemoglobin and erythrocyte levels.

d.

paresthesia in the fingers.

ANS: C

Treatment of pernicious anemia first focuses on increasing hemoglobin level with cobalamin (vitamin B12). This will raise total RBC counts. However, sometimes the hemoglobin level fails to rise in proportion to an increased RBC count, either because the rapid regeneration of RBCs depletes iron stores, or because iron deficiency may be a part of the etiology of pernicious anemia. The client may need oral iron supplementation if the hemoglobin level fails to rise in proportion to an increased RBC count.

DIF: Analysis/Analyzing REF: p. 2020 OBJ: Assessment

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Expected Effects/Outcomes

13. A nurse is conducting a home safety check on a client with cobalamin/vitamin B12 deficiency. What inquiries should the nurse specifically make?

a.

Evidence of adequate lighting

b.

How many stairs the client must negotiate to get inside

c.

Number and location of throw rugs

d.

Temperature setting on the water heater

ANS: D

In pernicious anemia, the production of myelin on nerves is greatly affected, resulting in neurologic impairment. Clients may injure themselves because of diminished sensitivity to heat and pain. The client may not notice a burn starting from bath water that is too hot.

DIF: Analysis/Analyzing REF: pp. 2019, 2020

OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Home Safety

14. The statement made by a client with pernicious anemia that would indicate to the nurse a need for further teaching is

a.

I promise to have a checkup every 6 months.

b.

Im glad my nervous problems will not get worse.

c.

Monthly injections are not so bad.

d.

Physical therapy will help get rid of my palpitations.

ANS: D

The response to injections is quick and dramatic. By the end of the first week the total RBC count rises significantly. Cardiovascular involvement usually lessens with improved erythropoiesis. Peripheral nerve function may improve with treatment.

DIF: Analysis/Analyzing REF: p. 2020 OBJ: Evaluation

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Expected Effects/Outcomes

15. The nursing diagnosis that would have priority in the care of a client with agranulocytosis is

a.

alteration in bowel elimination: Constipation due to iron overload.

b.

Impaired Gas Exchange due to low RBC count.

c.

potential for Impaired Skin Integrity due to poor nutritional status.

d.

Risk for Infection due to decreased leukocyte count.

ANS: D

The client suffers from an increased susceptibility to infection because without leukocytes the body cannot adequately battle bacteria and other invading organisms. Without prompt recognition and treatment, a slight infection can produce septicemia and death within a week.

DIF: Analysis/Analyzing REF: p. 2028 OBJ: Diagnosis

MSC: Safe, Effective Care Environment Safety and Infection Control

16. A child with hemophilia requires frequent emergency infusions of antihemophilic factor replacement therapy (AHF). The mother becomes distraught during one infusion and starts crying, saying Its all my fault my child has to suffer so! An appropriate intervention by the nurse would be to

a.

call the social worker to come sit with the mother during the infusion.

b.

explain to the mother that it was the father who gave the child hemophilia.

c.

gently remind the mother that she cannot control genetics.

d.

offer resources to teach the mother home AHF infusion technique.

ANS: D

The mother is feeling guilty and powerless. Offering her the opportunity to learn to give the AHF infusions at home might give her some control back. Prophylactic infusions at home decreases bleeding episodes and complications with the result that the client misses less time at school or work and suffers fewer complications. Hemophilia is an X-linked genetic defect. Males do not transmit the defect to their sons, but all their daughters will be carriers. A social worker could come sit with the mother and offer support, but this avoids the nurses responsibility to the mother. Reminding the mother she cannot control genetics is dismissive and unhelpful.

DIF: Analysis/Analyzing REF: p. 2038 OBJ: Assessment

MSC: Psychosocial Integrity Coping and Adaptation-Coping Mechanisms

17. A client has a hemoglobin level of 8.2 g/dl. The nurse finds the client dyspneic with an O2 saturation of 98%. The client has oxygen on at 2 liters per nasal cannula. Which intervention by the nurse would be best to meet this clients needs?

a.

Call the physician and suggest a transfusion.

b.

Find another oximeter and check another saturation.

c.

Increase the O2 to 6 liters per nasal cannula.

d.

Prepare to intubate and mechanically ventilate the client.

ANS: A

This client is anemic, meaning there is not enough hemoglobin to carry the amount of oxygen the client needs. The oximeter may be correct; all 8.2 g/dl of hemoglobin may be 98% saturated with oxygen, but there still is not enough oxygen to meet the clients needs. Turning up the oxygen will not help. The client needs a transfusion in order to boost the circulating hemoglobin in the bloodstream. If the client does not respond to this or if the client becomes more unstable, it may be necessary to intubate; however, being anemic will still prevent the client from receiving adequate oxygen.

DIF: Analysis/Analyzing REF: p. 2005 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Medical Emergencies

18. The nurse recognizes that the laboratory finding indicative of polycythemia vera is

a.

erythrocyte count of 5 million/mm3.

b.

hemoglobin level of 22 g/100 ml.

c.

leukocyte count of 6000/mm3.

d.

platelets of 50,000/mm3.

ANS: B

Diagnostic findings include RBC count as high as 8 to 12 million/mm3, hemoglobin level of 18 to 25 g/dl, and a hematocrit level greater than 54% in men and 49% in women.

DIF: Comprehension/Understanding REF: p. 2026 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

19. The nurse caring for a client with polycythemia vera explains the objective of phlebotomies is to decrease the hematocrit to

a.

15%.

b.

25%.

c.

35%.

d.

45%.

ANS: D

Phlebotomies can be used to normalize red cell mass until the hematocrit reaches 45%.

DIF: Comprehension/Understanding REF: pp. 2026-2027

OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Therapeutic Procedures

20. The manifestation that would require immediate investigation in a client with infectious mononucleosis is

a.

abdominal pain.

b.

joint discomfort.

c.

leukocyte count of 12,000/mm3.

d.

sore throat.

ANS: A

When infectious mononucleosis is severe, the client may develop splenic rupture resulting from the infiltration of the spleen by massive numbers of lymphocytes. Joint discomfort is not a typical complaint, although muscle aches and pains are. The leukocyte count typically ranges from 12,000 to 20,000/mm3. Sore throats are common in mononucleosis.

DIF: Application/Applying REF: p. 2030 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

21. A client is recovering from mononucleosis but is upset that 12 weeks after diagnosis she is still too weak to resume normal household and work chores. The client states that the spouse and children are getting very tired of doing everything while the client just sits around. The most appropriate response by the nurse is to tell the client

a.

convalescence is lengthy and people often report fatigue as late as 6 months later.

b.

further diagnostic testing may be necessary to determine the cause of the fatigue.

c.

it has been long enough now to start resuming normal activities.

d.

medications exist that can boost strength and endurance after mononucleosis.

ANS: A

Convalescence after mononucleosis is lengthy with some people reporting fatigue for up to 6 months. There are no treatments that mitigate or shorten the disease process.

DIF: Application/Applying REF: p. 2030 OBJ: Intervention

MSC: Psychosocial Integrity Coping and Adaptation-Situational Role Changes

22. The nurse counsels a client with idiopathic thrombocytopenic purpura (ITP) that if medication therapy is not effective, the surgical procedure most likely to be used in the treatment is

a.

bone marrow transplant.

b.

exploratory laparotomy.

c.

hepatic shunt.

d.

splenectomy.

ANS: D

If the client does not have a sustained remission, splenectomy may be needed. In 60% to 80% of cases, removal of the spleen results in complete and permanent remission.

DIF: Comprehension/Understanding REF: p. 2033 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

23. The nurse assessing a client with sickle cell anemia would recognize the common manifestation of the disease is

a.

confusion.

b.

diarrhea.

c.

hypertension.

d.

leg ulcers.

ANS: D

Leg ulcers are found in about 75% of older children and adults with the disease. Diarrhea is not seen. The most common cardiovascular manifestation is heart failure. Stroke is a common neurologic outcome.

DIF: Application/Applying REF: pp. 2023, 2024

OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

24. The nurse explains that the definitive laboratory finding confirming the diagnosis of sickle cell anemia is

a.

folate deficiency.

b.

hemoglobin level of less than 9 g/dl.

c.

increase in hemoglobin G (Hgb G).

d.

presence of hemoglobin S (Hgb S).

ANS: D

The presence of Hgb S is the definitive finding that confirms the diagnosis of sickle cell anemia.

DIF: Comprehension/Understanding REF: p. 2022 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

25. A client who has hemophilia A and his wife, who is not a carrier of the disease, wish to start a family. In discussing the risk factors of transmitting hemophilia to his children, it is important to explain that

a.

none of his children are likely to have hemophilia.

b.

all of his children will be carriers.

c.

all of his sons will have hemophilia.

d.

50% of his children are at risk for developing the disease.

ANS: A

Hemophilia is genetically transmitted in a sex-linked (X chromosome) recessive pattern. Female carriers will transmit the defective gene to 50% of their sons, and 50% of their daughters will be carriers. Males express the bleeding disorder. Males with hemophilia transmit the gene to all of their daughters, who become carriers, but to none of their sons. A female can be a hemophiliac in the rare instance of a male hemophiliac producing a daughter with a mother who is a carrier.

DIF: Analysis/Analyzing REF: p. 2036 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

26. The nursing intervention that is the priority when preparing to administer blood is

a.

administration of pretransfusion antihistamines.

b.

asking a second health care professional to confirm blood acceptability.

c.

establishing baseline vital signs.

d.

obtaining a written order for the transfusion.

ANS: B

All options are reasonable. Baseline vitals are important to compare against subsequent ones. There will be a written order for the transfusion at some point; either the physician or the nurse will write the order. Some clients will need premedication before a transfusion, but the most critical phase of transfusion is confirming product compatibility and verifying client identity. Most transfusion reactions can be traced to improper product-to-patient identification. Two professional nurses are required to perform that task.

DIF: Application/Applying REF: p. 2015 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities

27. The nurse can decrease the danger of transfusion reactions in a client by

a.

adding sterile saline to the blood transfusion.

b.

forcing fluids.

c.

infusing the blood slowly during the first 15 minutes.

d.

monitoring the urine output.

ANS: C

It is recommended that the transfusion begin slowly and that the client be closely monitored. If no evidence of a reaction is noted within the first 15 minutes, flow can then be increased to the prescribed rate.

DIF: Application/Applying REF: pp. 2015-2016

OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Blood and Blood Products

28. When a client experiences an adverse reaction to a blood transfusion, the nurse should initially

a.

administer oxygen via nasal prongs.

b.

discontinue the transfusion.

c.

notify the physician.

d.

raise the head of the bed.

ANS: B

In all cases of transfusion reaction, stop the transfusion and keep the intravenous (IV) line open with normal saline. The physician will need to be notified, but the first action is to stop the blood. The clients condition may warrant administering oxygen or raising the head of the bed to assist with breathing.

DIF: Application/Applying REF: p. 2016 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Blood and Blood Products

29. The nurse recognizes that manifestations seen in a client with agranulocytosis are the result of

a.

elevated granulocytes.

b.

hypoprothrombinemia.

c.

profound neutropenia.

d.

thrombocytosis.

ANS: C

The manifestations of agranulocytosis are a result of the neutropenia. Agranulocytosis is a disorder of the white blood cells.

DIF: Comprehension/Understanding REF: p. 2028 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

30. A client has folic acid deficiency anemia. Which information in the nursing history would be of concern to the nurse? The client

a.

cooks in cast iron skillets.

b.

does not like to eat fish.

c.

has one alcoholic drink a week.

d.

takes metformin.

ANS: D

Metformin impairs folate uptake in the ileum.

DIF: Analysis/Analyzing REF: p. 2037 OBJ: Assessment

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Adverse Effects/Contraindications

31. When assessing the client with multiple myeloma, the nurse would expect to find the manifestation of

a.

bone pain.

b.

ecchymosis of the skin.

c.

painless enlarged lymph nodes.

d.

shortness of breath.

ANS: A

Once manifestations appear, they typically involve the skeletal system, particularly the pelvis, spine, and ribs. Some clients have backache or bone pain that worsens with movement.

DIF: Application/Applying REF: p. 2029 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems

32. A client has been newly diagnosed with multiple myeloma and is going to be followed up with frequent, close monitoring. The client states Im glad at least that this disease is not so bad. I was really worried theyd find something really wrong. What response by the nurse is most appropriate?

a.

Agree with the client that he/she is quite lucky.

b.

Ask the client what the physician has told him/her about the disease.

c.

Explain the complicated drug regimen that will start once the client has symptoms.

d.

Warn the client that there will be days when he/she feels really bad.

ANS: B

In the initial phases when clients are asymptomatic, they are often carefully monitored until the disease progresses and then are treated with chemotherapy. However, the disease is always fatal and clients and their families need education and possibly counseling to deal with the fatal outcome of the disease. The best response by the nurse is to start that conversation by assessing exactly what the client understands about the disease.

DIF: Application/Applying REF: pp. 2029, 2030

OBJ: Intervention

MSC: Psychosocial Integrity Coping and Adaptation-Therapeutic Interactions

33. The nurse planning care of a client with multiple myeloma includes the intervention of

a.

administering frequent mouth care.

b.

encouraging ingestion of dairy products.

c.

forcing fluids.

d.

maintaining reverse isolation.

ANS: C

Clients with multiple myeloma usually require about 3 L of fluid per day. The client needs sufficient fluid not only to dilute the calcium overload but also to prevent protein from precipitating in the renal tubules, even after being effectively treated with chemotherapy. The other options are not included in the plan of care for this client.

DIF: Application/Applying REF: pp. 2029-2030

OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

34. When teaching a client who has multiple myeloma about self-care in the home, the nurse should advise the client and family take appropriate precautions to

a.

alleviate diarrhea.

b.

prevent fractures.

c.

prevent seizures.

d.

protect visitors.

ANS: B

Some clients have backache or bone pain that worsens with movement. Others suffer sudden pathologic fractures accompanied by severe pain. Because of skeletal complications, care should be taken when moving the client. Family members should institute safety measures to prevent falls.

DIF: Application/Applying REF: p. 2030 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention

35. An important self-care measure the nurse teaches a client who has sickle cell disease is to

a.

avoid crowds and people who are sick.

b.

eat a well-balanced diet with plenty of fiber.

c.

get plenty of vigorous exercise daily.

d.

have genetic testing done if contemplating children.

ANS: A

Sickle cell crises can be brought on by anything that causes a reduced oxygen situation or by things like stress, cold, and infection. Avoiding crowds and people who are ill might reduce the number of crises a client with SCD has. A well-balanced, fiber-enriched diet is healthy for everyone, but is not specific to SCD. Vigorous exercise might induce a crisis. Genetic testing, while important for the general population of African Americans, is of no use to someone who has the disease.

DIF: Application/Applying REF: p. 2023 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

MULTIPLE RESPONSE

1. A client presents to the emergency department having a severe sickle cell crisis. The nurse should be prepared to do which of the following interventions? (Select all that apply.)

a.

Administer oxygen.

b.

Offer heat therapy.

c.

Order hydroxyurea from the pharmacy.

d.

Prepare to give IV morphine.

e.

Start an IV with normal saline.

ANS: A, B, D, E

Care of the client in sickle cell crisis includes administering oxygen, providing heat for painful joints, giving IV opioids (morphine is preferred), and providing hydration with IV fluids. Hydroxyurea has been approved by the FDA for SSD, but is given long-term to clients for whom other treatments are not effective and who have frequent, painful crises.

DIF: Application/Applying REF: pp. 2024-2025

OBJ: Intervention

MSC: Physiological Adaptation Physiological Adaptation-Medical Emergencies

2. To increase the safety of a blood transfusion, which of the following actions should the nurse take? The nurse should prepare to administer the blood with (Select all that apply)

a.

a second nurse to take the vital signs.

b.

a tubing set designed for blood products.

c.

an IV of D5W.

d.

an IV of normal saline.

ANS: B, D

To prevent hemolysis, add no solution other than normal saline to blood components. Following institutional policy, use a tubing set designed for blood products. Most will contain a filter that will trap small fibrin clots and other cellular debris. A second nurse is used during the identity-verification step.

DIF: Application/Applying REF: p. 2015 OBJ: Intervention

MSC: Physiological Adaptation Pharmacological and Parenteral Therapies-Blood and Blood Products

3. When administering a blood transfusion to a client, which tasks can the nurse delegate to the experienced unlicensed personnel? (Select all that apply.)

a.

Assisting the client to a comfortable position

b.

Reporting any complaints to the physician

c.

Taking the clients vital signs

d.

Verifying the clients identity with the nurse

ANS: A, C

Two professional nurses are required to verify the clients identity and verify the blood product being used is correct. An unlicensed personnel can assist the client to a comfortable position and can take (and usually chart) the clients vital signs. Any client complaints should be reported to the nurse, not the physician, by the unlicensed personnel.

DIF: Application/Applying REF: pp. 2015, 2016

OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Delegation

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

Leave a Reply