Questions 4-7

A nurse is caring for a client with thrombocytopenia. Which interventions are appropriate? Select all that apply.

• Apply pressure to bleeding sites for 10 minutes

• Assist with ambulation as tolerated

• Obtain rectal temperatures every 4 hours

• Measure and document urine output

• Use electric razor for shaving

The nurse is caring for a client with erythrocytosis. Which interventions reduce the client’s risk for the most serious complication? Select all that apply.

• Encourage use of sequential compression devices (SCDs)

• Promote hydration

• Administer iron supplements

• Encourage early ambulation

• Apply ice packs to extremities

A nurse is caring for a client experiencing a febrile transfusion reaction. Which clinical manifestations would support this diagnosis? Select all that apply.

• Fever

• Chills

• Flank pain

• Hypotension

• Headache

Which signs/symptoms are most consistent with an acute hemolytic transfusion reaction? Select all that apply.

• Hematuria

• Fever and chills

• Low back pain

• Signs of shock

• Urticaria

A nurse suspects a client is experiencing an allergic transfusion reaction. Which cues would the nurse expect? Select all that apply.

• Hives

• Itching

• Flushing

• Dyspnea

• Anxiety

Signs of fluid overload during a blood transfusion include which of the following?

• Shortness of breath, and increased blood pressure

• Fever, chills, and back pain

• Rash, itching, and hives

• Nausea, vomiting, and diarrhea

Which of the following clients is receiving an appropriate type of blood for their blood type? Select all that apply.

• Client with B negative receiving O negative blood

• Client with B negative receiving B negative blood

• Client with B negative receiving B positive blood

• Client with B negative receiving O positive blood

The nurse is teaching about evaluating transfusion effectiveness for a client receiving RBCs. Which outcomes indicate success? Select all that apply.

• Hemoglobin increases by 1 g/dL per unit transfused

• Hematocrit decreases by 3%

• Improved oxygenation and energy levels

• Increased Prothrombin Time

• No transfusion reaction symptoms

Identify the incorrect nursing interventions for a client with erythrocytosis from the following options.

• Encouraging frequent ambulation to prevent thrombosis

• Applying warm compresses to promote circulation

• Restricting fluid intake to reduce blood volume

• Monitoring for signs of bleeding and thrombosis

A nurse caring for a client with thrombocytopenia should intervene if which actions are observed? Select all that apply.

• Taking an oral temperature

• Measuring urine output hourly

• Obtaining a rectal temperature

• Assisting with ambulation