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. 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.

3. Which patient should the nurse assign as the roommate for a patient who has aplastic anemia?

• A. A patient with chronic heart failure
• B. A patient who has viral pneumonia
• C. A patient who has right leg cellulitis
• D. A patient with multiple abdominal drains

Correct answer: A

Rationale: The correct answer is A because patients with aplastic anemia are at risk for infection due to low white blood cell production. Assigning a roommate with viral pneumonia (choice B), cellulitis (choice C), or multiple abdominal drains (choice D) could expose the patient with aplastic anemia to potential infectious agents, which could further compromise their health.

4. A 44-year-old with sickle cell anemia who says his eyes always look sort of yellow

• A. A 23-year-old with no previous health problems who has a nontender lump in the axilla
• B. A 50-year-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue
• C. A 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement
• D. A 44-year-old with sickle cell anemia who says his eyes always look sort of yellow

Correct answer: B

Rationale: Choice B is the correct answer because the scenario describes a 50-year-old with early-stage chronic lymphocytic leukemia who presents with chronic fatigue. Chronic lymphocytic leukemia commonly presents with symptoms like fatigue, weight loss, and enlarged lymph nodes. The other choices are less likely as they do not match the clinical presentation described in the scenario. Choice A describes a 23-year-old with a nontender lump in the axilla, which is more suggestive of a benign condition like a lipoma. Choice C describes a 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement, which is unrelated to the symptoms of chronic lymphocytic leukemia. Choice D repeats the scenario, which is not relevant in selecting the appropriate answer.

5. The nurse is reviewing laboratory results and notes a patient's activated partial thromboplastin time (aPTT) level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication?

• A. Aspirin
• B. Heparin
• C. Warfarin
• D. Erythropoietin

Correct answer: B

Rationale: The correct answer is B: Heparin. An activated partial thromboplastin time (aPTT) level of 28 seconds indicates a prolonged time, which is associated with heparin administration. Heparin is an anticoagulant medication that affects the intrinsic pathway of the coagulation cascade, leading to an increased aPTT. Aspirin (choice A) affects platelet aggregation and does not directly impact aPTT. Warfarin (choice C) affects the extrinsic pathway of the coagulation cascade and is monitored using the international normalized ratio (INR), not aPTT. Erythropoietin (choice D) is not related to coagulation parameters.

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