Nursing Elites

1. An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to

• A. provide a diet high in vitamin K
• B. alternate periods of rest and activity
• C. teach the patient how to avoid injury
• D. place the patient on protective isolation

Correct answer: B

Rationale: In severe hemolytic anemia, the priority nursing intervention is to alternate periods of rest and activity. This approach helps to balance activity levels to prevent excessive fatigue while promoting mobility and preventing complications such as muscle weakness or deconditioning. Providing a diet high in vitamin K (choice A) is not directly related to managing hemolytic anemia. Teaching the patient how to avoid injury (choice C) is important but may not be the immediate priority. Placing the patient on protective isolation (choice D) is not indicated for hemolytic anemia, as it is not a contagious condition.

2. The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take before this procedure?

• A. Check for any iodine allergy.
• B. Insert a large-bore IV catheter.
• C. Administer prescribed sedatives.
• D. Assist the patient to a flat position.

Correct answer: D

Rationale: Before a liver and spleen scan, it is essential to assist the patient to a flat position. This position helps obtain clear images of the liver and spleen. Checking for iodine allergy (Choice A) is more relevant for procedures involving contrast dye, not a liver and spleen scan. Inserting a large-bore IV catheter (Choice B) may not be necessary for this specific procedure. Administering sedatives (Choice C) is not typically required for a liver and spleen scan, as the patient needs to remain still during the procedure.

3. Which patient requires the most rapid assessment and care by the emergency department nurse?

• A. The patient with hemochromatosis who reports abdominal pain
• B. The patient with neutropenia who has a temperature of 101.8°F
• C. The patient with thrombocytopenia who has oozing gums after a tooth extraction
• D. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours

Correct answer: B

Rationale: The correct answer is B because a neutropenic patient with a fever is at high risk for developing sepsis. Sepsis can progress rapidly and lead to life-threatening complications. Immediate assessment, obtaining cultures, and initiating antibiotic therapy are essential in this situation. Choices A, C, and D do not present with the same level of urgency as a neutropenic patient with a fever. Abdominal pain in a hemochromatosis patient, oozing gums after a tooth extraction in a thrombocytopenic patient, and nausea and diarrhea in a patient with sickle cell anemia, while concerning, do not indicate the same immediate risk of sepsis as a neutropenic patient with a fever.

4. A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the healthcare provider before obtaining and administering platelets?

• A. Platelet count is 42,000/µL
• B. Petechiae are present on the chest
• C. Blood pressure (BP) is 94/56 mm Hg
• D. Blood is oozing from the venipuncture site

Correct answer: A

Rationale: The correct answer is A. Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/µL unless the patient is actively bleeding. In this case, with a platelet count of 42,000/µL, the count is not critically low, and the patient is not actively bleeding. Therefore, the nurse should consult with the healthcare provider before giving the transfusion. Choices B, C, and D are incorrect because the presence of petechiae, low blood pressure, and oozing from the venipuncture site are common findings in patients with ITP and do not necessarily require immediate consultation before administering a platelet transfusion.

5. The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care?

• A. Avoid intramuscular injections.
• B. Encourage increased oral fluids.
• C. Check temperature every 4 hours.
• D. Increase intake of iron-rich foods.

Correct answer: A

Rationale: The correct action to include in the plan of care for a thrombocytopenic patient is to avoid intramuscular injections. Thrombocytopenia is a condition characterized by a decreased number of platelets, which are essential for blood clotting. Intramuscular injections can pose a risk of bleeding in patients with low platelet counts. Encouraging increased oral fluids (choice B) is beneficial for hydration but does not directly address the risk of bleeding associated with thrombocytopenia. Checking temperature every 4 hours (choice C) is important for monitoring infection but does not specifically address the risk of bleeding. Increasing intake of iron-rich foods (choice D) is more related to addressing anemia, not the primary concern of bleeding in thrombocytopenia.

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