Question

A nurse is reinforcing teaching with a client has a new diagnosis of aplastic anemia. When discussing the pathology of this disease, which of the following instructions should the nurse include in the teaching?

Answer 1

Correct Answers:

"Aplastic anemia results from decreased bone marrow production of RBCs."

Rationale :

🟥 Aplastic anemia is a disorder where the bone marrow fails to produce adequate red blood cells, white blood cells, and platelets.

🟥 This condition causes pancytopenia, increasing susceptibility to infection, anemia, and bleeding.

🟥 It is not caused by impaired liver function, nor by poor dietary iron intake.

🟥 It is distinct from hemolytic anemia, which involves premature destruction of RBCs.

🟥 Management includes bone marrow stimulants, transfusions, or even stem cell transplant in severe cases.

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Answer 2

Correct Answers:

Use soft toothbrush with oral care

Rationale :

🟡 Low platelets put the client at risk of bleeding from even minor trauma like brushing.

🟡 A soft toothbrush minimizes gum injury and bleeding risk.

🟡 Clients should avoid razors and other sharp tools that could cause cuts.

🟡 Hot liquids may irritate the mucosa and promote bleeding in thrombocytopenia.

🟡 Implementing bleeding precautions is standard for platelet counts under 20,000/mm³.

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Answer 3

Correct Answers:

28

Rationale :

🔵 Use the formula: (Volume × Drop Factor) ÷ Time in minutes.

🔵 (1000 mL × 10 gtt/mL) ÷ 360 = 27.78, rounded to 28 gtt/min.

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Answer 4

Correct Answers:

Temperature

Rationale :

🔴 Baseline temperature helps detect febrile transfusion reactions quickly.

🔴 A sudden temperature rise during transfusion can indicate hemolysis or allergy.

🔴 It's part of vital pre-transfusion assessments.

🔴 Skin color and fluid intake are secondary priorities before a transfusion.

🔴 Early detection prevents serious complications like shock.

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Answer 5

Correct Answers:

Sternum

Rationale :

🟪 The sternum is a common site for bone marrow aspiration in adults aside from the iliac crest.

🟪 It offers a direct, safe access to marrow when properly performed.

🟪 The cervical spine and humerus are not used due to safety concerns.

🟪 Sternum access is typically done under local anesthesia.

🟪 This site is particularly useful for bedridden or obese clients.

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Answer 6

Correct Answers:

Low back pain

Rationale :

⚫ Low back pain is a hallmark sign of an acute hemolytic transfusion reaction.

⚫ It results from hemoglobin release and renal involvement due to RBC destruction.

⚫ This pain typically occurs in the kidney area, suggesting damage or inflammation.

⚫ Immediate intervention is crucial to prevent renal failure or shock.

⚫ Other symptoms may include fever, chills, and hypotension, but low back pain is most specific.

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Answer 7

Correct Answers:

4 hr

Rationale :

🟫 Packed RBCs must be infused within 4 hours to prevent bacterial contamination.

🟫 Prolonged transfusions increase the risk of sepsis and hemolysis.

🟫 This time frame is standard regardless of volume or patient age.

🟫 Even in slower transfusions, infusion must not exceed 4 hours.

🟫 Monitor the patient throughout for signs of transfusion reactions.

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Answer 8

Correct Answers:

Excessive thrombosis and bleeding.

Rationale :

🔶 DIC involves simultaneous clotting and bleeding due to clotting factor depletion.

🔶 Clots form throughout the small vessels, leading to organ ischemia.

🔶 Eventually, clotting factors and platelets are exhausted, causing bleeding.

🔶 It is often triggered by sepsis, trauma, or malignancy.

🔶 Requires prompt care with heparin, plasma, or platelet transfusions.

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Answer 9

Correct Answers:

Skin assessment
Breath sounds
Oxygen saturation
Retractions
Respiratory rate

Rationale :

🔹 Skin bruises and pallor suggest anemia and thrombocytopenia from leukemia.

🔹 Rhonchi in breath sounds indicate potential respiratory infection.

🔹 Oxygen saturation drop to 90% is a red flag for hypoxia.

🔹 Subcostal retractions reflect labored breathing and early respiratory distress.

🔹 Tachypnea (RR 30/min) confirms worsening respiratory effort.

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Answer 10

Correct Answers:

The spleen is the primary site for platelet destruction.

Rationale :

🟨 In ITP, the spleen removes platelets prematurely, leading to thrombocytopenia.

🟨 A splenectomy helps reduce unnecessary platelet destruction.

🟨 It's considered when medical therapy fails (e.g., steroids, IVIG).

🟨 Removing the spleen can lead to sustained increases in platelet count.

🟨 Patients need lifelong vaccination and infection precautions post-splenectomy.

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QLexNursing

1 :
A nurse is reinforcing teaching with a client has a new diagnosis of aplastic anemia. When discussing the pathology of this disease, which of the following instructions should the nurse include in the teaching?

2 :
The nurse is caring for a patient with a platelet count of <20,000/mm3 (150,000-400000). Which of the following precautions should the nurse take in providing care for this patient?

4 :
A nurse is collecting data on a client who is to receive a blood transfusion. Which of the following data is the nurse's priority before the transfusion begins?

5 :
A nurse is reinforcing teaching with a client who is to have a bone marrow aspiration and biopsy. The nurse should tell the client that, in addition to the iliac crest, a common site for this procedure is which of the following?

6 :
A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?

7 :
A nurse is planning care for a client who is to receive one unit of packed RBCs. Within which of the following time spans must the nurse complete the infusion?

8 :
A nurse is reviewing data for a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

9 :
A pediatric nurse is assisting with the care of a school-age child who has leukemia.

Answer Options

10 :
The nurse is caring for a patient who must undergo a splenectomy for treatment for idiopathic thrombocytopenic purpura (ITP). Which of the following statements best describes the rationale for the splenectomy?

QLexNursing

1 : A nurse is reinforcing teaching with a client has a new diagnosis of aplastic anemia. When discussing the pathology of this disease, which of the following instructions should the nurse include in the teaching?

2 : The nurse is caring for a patient with a platelet count of <20,000/mm3 (150,000-400000). Which of the following precautions should the nurse take in providing care for this patient?

4 : A nurse is collecting data on a client who is to receive a blood transfusion. Which of the following data is the nurse's priority before the transfusion begins?

5 : A nurse is reinforcing teaching with a client who is to have a bone marrow aspiration and biopsy. The nurse should tell the client that, in addition to the iliac crest, a common site for this procedure is which of the following?

6 : A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?

7 : A nurse is planning care for a client who is to receive one unit of packed RBCs. Within which of the following time spans must the nurse complete the infusion?

8 : A nurse is reviewing data for a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

9 : A pediatric nurse is assisting with the care of a school-age child who has leukemia.

Answer Options

10 : The nurse is caring for a patient who must undergo a splenectomy for treatment for idiopathic thrombocytopenic purpura (ITP). Which of the following statements best describes the rationale for the splenectomy?

1 :
A nurse is reinforcing teaching with a client has a new diagnosis of aplastic anemia. When discussing the pathology of this disease, which of the following instructions should the nurse include in the teaching?

2 :
The nurse is caring for a patient with a platelet count of <20,000/mm3 (150,000-400000). Which of the following precautions should the nurse take in providing care for this patient?

4 :
A nurse is collecting data on a client who is to receive a blood transfusion. Which of the following data is the nurse's priority before the transfusion begins?

5 :
A nurse is reinforcing teaching with a client who is to have a bone marrow aspiration and biopsy. The nurse should tell the client that, in addition to the iliac crest, a common site for this procedure is which of the following?

6 :
A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?

7 :
A nurse is planning care for a client who is to receive one unit of packed RBCs. Within which of the following time spans must the nurse complete the infusion?

8 :
A nurse is reviewing data for a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

9 :
A pediatric nurse is assisting with the care of a school-age child who has leukemia.

10 :
The nurse is caring for a patient who must undergo a splenectomy for treatment for idiopathic thrombocytopenic purpura (ITP). Which of the following statements best describes the rationale for the splenectomy?