University:
West Coast University
Course:
NURS 122 | Introduction to Medical Surgical Nursing
Academic year:

2021
Views:

334

Pages:

1
Author:

esfredint7qo

Question2A client with Hodgkin disease had a bone marrow biopsy yesterday and reports aching at the biopsy site, rated a 5 (on a 1–10 scale). After assessing the biopsy site, which nursing intervention is most appropriate?  Administer acetaminophen 500 mg po, as ordered Explanation:After a marrow sample is obtained, pressure is applied to the site for several minutes. The site is then covered with a sterile dressing. Most clients have no discomfort after a bone marrow biopsy, but the site of a biopsy may ache for 1 or 2 days. Warm tub baths and a mild analgesic agent (e.g., acetaminophen) may be useful. Aspirin-containing analgesic agents should be avoided it the immediate post-procedure period because they can aggravate or potentiate bleeding. Question3When conducting a health assessment on a client suspected for having a hematological disorder, the nurse should collect which data? Select all that apply.  Dietary intake; Medication use; Ethnicity; Herbal supplements Explanation:Dietary intake, ethnicity, use of herbal supplements, and medication use are factors for which the nurse should assess. Hair color is not considered a factor in determining causes of hematological disorders. Question4The client's CBC with differential reveals small-shaped hemoglobin molecules. The nurse expects to administer which medication to this client?  Iron Explanation:With iron deficiency, the erythrocytes produced by the marrow are small and low in hemoglobin. Vitamin B12 and folate deficiencies are characterized by the production of abnormally large erythrocytes. Fresh frozen plasma is infused due to a low platelet level, not light-colored hemoglobin. Question5The nurse is administering a blood transfusion to a client over 4 hours. After 2 hours, the client reports chills and has a fever of 101°F, an increase from a previous temperature of 99.2°F. What does the nurse recognize is occurring with this client?  The client is having a febrile nonhemolytic reaction. Explanation:The signs and symptoms of a febrile nonhemolytic transfusion reaction are chills (minimal to severe) followed by fever (more than 1°C elevation). The fever typically begins within 2 hours after the transfusion is begun. Although the reaction is not life threatening, the fever, and particularly the chills and muscle stiffness, can be frightening to the client. Question10A nurse cares for a client with myelodysplastic syndrome who requires frequent PRBC transfusions. What blood component does the nurse recognize as being most harmful if accumulated in the tissues due to chronic blood transfusions?  Iron Explanation:Iron overload is a complication unique to people who have had long-term PRBC transfusion. Over time, the excess iron deposits in body tissues can cause organ damage, particularly in the liver, heart, testes, and pancreas.