RNSG 2539 EXAM 2 LATEST 2023-2024 ACTUAL
EXAM 228 QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS )
|ALREADY GRADED A+
A patient with a recent diagnosis of ITP has asked the nurse why the care team has not chosen to administer platelets, stating, 'I have low platelets, so why not give me a transfusion of exactly what I'm missing?' How should the nurse best respond?
- 'Transfused platelets usually aren't beneficial because they're rapidly
- 'A platelet transfusion often blunts your body's own production of
- 'Finding a matching donor for a platelet transfusion is exceedingly
- 'A very small percentage of the platelets in a transfusion are actually
destroyed in the body.'
platelets even further.'
difficult.'
functional.' - ANSWER- A) 'Transfused platelets usually aren't beneficial because they're rapidly destroyed in the body.'
In immune thrombocytopenia purpura (ITP), the client has what type of disorder that primarily destroys which blood component?
- Allergic; fibrinogen
- Alloimmune; factor VIII 1 / 4
- Autoimmune; platelets
- Immunoglobulin; B cells - ANSWER- C) Autoimmune; platelets
A client has been admitted for immune thrombocytopenic purpura. The client has not responded to corticosteroid treatment. The priority nursing intervention for this client would include which of the following treatment measures?
- Place the client in isolation, so the skin rashes will not spread to other
- Insert an intravenous catheter, so immune globulin can be
- Insert a Foley catheter to monitor hourly urine output.
- Prepare a surgical permit for an emergency splenectomy. -
clients.
administered in a timely manner.
ANSWER- B) Insert an intravenous catheter, so immune globulin can be administered in a timely manner.
A nurse is admitting a patient with immune thrombocytopenic purpura to the unit. In completing the admission assessment, the nurse must be alert for what medications that potentially alter platelet function? Select all that apply.
- Antihypertensives
- Penicillins
- Sulfa-containing medications
- Aspirin-based drugs 2 / 4
- NSAIDs - ANSWER- C) Sulfa-containing medications
- Aspirin-based drugs
- NSAIDs
A client was started on a protocol for the prevention of deep vein thrombosis shortly after admission and has been receiving 5000 units of heparin twice daily for the last week. An immune response to this treatment may increase the client's chance of developing which health problem?
- Antiphospholipid syndrome
- Disseminated intravascular coagulation (DIC)
- Von Willebrand disease
- Thrombocytopenia - ANSWER- D) Thrombocytopenia
When the nurse administers heparin it is anticipated the drug will have what action on the patient's body?
- Binds to factor X
- Blocks the formation of thrombin
- Binds to factor Xa
- Promotes the inactivation of factor VIII - ANSWER- B) Blocks the
- / 4
formation of thrombin
The nurse is reviewing the laboratory test results of a pregnant client.Which one of the following findings would alert the nurse to the development of HELLP syndrome?
- Hyperglycemia
- Elevated platelet count
- Leukocytosis
- Elevated liver enzymes - ANSWER- D) Elevated liver enzymes
A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the woman's serum magnesium levels. Which level would the nurse identify as therapeutic?
- 3.3 mEq/L
- 6.1 mEq/L
- 8.4 mEq/L
- 10.8 mEq/L - ANSWER- B) 6.1 mEq/L
A nurse is providing discharge education to a patient who has recently been diagnosed with a bleeding disorder. What topic should the nurse prioritize when teaching this patient?
- Avoiding buses, subways, and other crowded, public sites
- Avoiding activities that carry a risk for injury
- Keeping immunizations current
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