Which collaborative treatment would the nurse anticipate for the client diagnosed with DIC? 1. Administer oral anticoagulants. 2. Prepare for plasmapheresis.
Full Answer
What are the nursing care planning and goals for patients with DIC?
The following are the common nursing care planning and goals for clients with DIC: maintenance of hemodynamic status, maintenance of intact skin and oral mucosa, maintenance of fluid balance, maintenance of tissue perfusion, prevention of complications.
What does the nurse write a client problem of “activity intolerance”?
The nurse writes a client problem of “activity intolerance” for a client diagnosed with anemia. Which intervention should the nurse implement? 1. Pace activities according to tolerance. 2. Provide supplements high in iron and vitamins. 3. Administer packed red blood cells. 4. Monitor vital signs every four (4) hours. 1.
Which interventions should the nurse teach the client with aplastic anemia?
The nurse is planning the care of a client diagnosed with aplastic anemia. Which interventions should be taught to the client? Select all that apply. 1. Avoid alcohol. 2. Pace activities.
What should the nurse do if the client’s CBC indicates?
The client’s CBC indicates an RBC 6.0 (106) mm, Hgb 14.2 g d/L, Hct 42%, and platelets 69 (103) mm. Which intervention should the nurse implement? 1. Teach the client to use a soft-bristle toothbrush. 2. Monitor the client for elevated temperature. 3. Check the client’s blood pressure. 4. Hold venipuncture sites for one (1) minute.
The nurse is caring for clients on an oncology unit. Which neutropenia precautions should be implemented? 1. Hold all venipuncture sites for at least five (5) minutes. 2. Limit fresh fruits and flowers. 3. Place all clients in reverse isolation. 4. Have the client use a soft-bristle toothbrush.
2. Fresh fruits and flowers may carry bacteria or insects on the skin of the fruit or dirt on the flowers and leaves, so they are restricted aro...
The nurse is assessing a client diagnosed with acute myeloid leukemia. Which assessment data support this diagnosis? 1. Fever and infections. 2. Nausea and vomiting. 3. Excessive energy and high platelet counts. 4. Cervical lymph node enlargement and positive acid-fast bacillus.
1. Fever and infection are hallmark symptoms of leukemia. They occur because the bone marrow is unable to produce white blood cells of the numbe...
The client diagnosed with leukemia has central nervous system involvement. Which instructions should the nurse teach? 1. Sleep with the head of the bed elevated to prevent increased intracranial pressure. 2. Take an analgesic medication for pain only when the pain becomes severe. 3. Explain that radiation therapy to the head may result in permanent hair loss. 4. Discuss end-of-life decisions prior to cognitive deterioration.
3. Radiation therapy to the head and scalp area is the treatment of choice for central nervous system involvement of any cancer. Radiation thera...
The client diagnosed with leukemia is scheduled for a bone marrow transplant. Which interventions should be implemented to prepare the client for this procedure? Select all that apply. 1. Administer high-dose chemotherapy. 2. Teach the client about autologous transfusions. 3. Have the family members’ HLA typed 4. Monitor the complete blood cell count daily. 5. Provide central line care per protocol.
1. All of the bone marrow cells must be destroyed prior to “implanting” the healthy bone marrow. High-dose chemotherapy and full-body irradiatio...
The client is diagnosed with chronic lymphocytic leukemia (CLL) after routine laboratory tests during a yearly physical. Which is the scientific rationale for the random nature of discovering the illness? 1. CCL is not serious, and clients die from other causes first. 2. There are no symptoms with this form of leukemia. 3. This is a childhood illness and is self-limiting. 4. In early stages of CLL the client may be asymptomatic.
4. In this form of leukemia the cells seem to escape apoptosis (programmed cell death), which results in many thousands of mature cells clogging...
The client diagnosed with leukemia is being admitted for an induction course of chemotherapy. Which laboratory values indicate a diagnosis of leukemia? 1. A left shift in the white blood cell count differential. 2. A large number of WBCs that decreases after the administration of antibiotics. 3. An abnormally low hemoglobin (Hgb) and hematocrit (Hct) level. 4. Red blood cells that are larger than normal.
1. A left shift indicates that immature white blood cells are being produced and released into the circulating blood volume. This should be inve...
Which medication is contraindicated for a client diagnosed with leukemia? 1. Bactrim, a sulfa antibiotic. 2. Morphine, a narcotic analgesic. 3. Epogen, a biologic response modifier. 4. Gleevec, a genetic blocking agent.
3. Epogen is a biologic response modifier that stimulates the bone marrow to produce red blood cells. The bone marrow is the area of malignancy in...
The laboratory results for a male client diagnosed with leukemia include RBC count 2.1 mm 106, WBC 150 mm 103, platelets 22 103, K 3.8 mEq/L, Na 139mEq/L. Based on these results, which interventions should the nurse teach the client? 1. Encourage the client to eat foods high in iron. 2. Instruct the client to use an electric razor when shaving. 3. Discuss the importance of limiting sodium in the diet. 4. Instruct the family to limit visits to once a week.
2. The platelet count of 22 103 indicates a platelet count of 22,000. The definition of thrombocytopenia is a count less than 100,000. This cli...
The nurse writes a nursing problem of “altered nutrition” for a client diagnosed with leukemia who has received a treatment regimen of chemotherapy and radiation. Which nursing intervention should be implemented? 1. Administer an antidiarrheal medication prior to meals. 2. Monitor the client’s serum albumin levels. 3. Assess for signs and symptoms of infection. 4. Provide skin care to irradiated areas,
2. Serum albumin is a measure of the protein content in the blood that is derived from the foods eaten; albumin monitors nutritional status.
What are the goals of nursing care for DIC patients?
The following are the common nursing care planning and goals for clients with DIC: maintenance of hemodynamic status, maintenance of intact skin and oral mucosa, maintenance of fluid balance, maintenance of tissue perfusion, prevention of complications.
What is DIC in coagulation?
Disseminated intravascular coagulation (DIC) is a coagulation disorder that prompts overstimulation of the normal clotting cascade and results in simultaneous thrombosis and hemorrhage. The formation of microclots affects tissue perfusion in the major organs, causing hypoxia, ischemia, and tissue damage. Coagulation occurs in two different pathways: intrinsic and extrinsic. These pathways are responsible for the formation of fibrin clots and blood clotting, which maintains homeostasis. In the intrinsic pathway, endothelial cell damage commonly occurs because of sepsis or infection. The extrinsic pathway is initiated by tissue injury such as from malignancy, trauma, or obstetrical complications. DIC may present as an acute or chronic condition.
What are the two pathways that regulate the formation of fibrin clots?
Coagulation occurs in two different pathways: intrinsic and extrinsic. These pathways are responsible for the formation of fibrin clots and blood clotting, which maintains homeostasis. In the intrinsic pathway, endothelial cell damage commonly occurs because of sepsis or infection.
Is DIC an acute or chronic condition?
DIC may present as an acute or chronic condition. An essential medical management of DIC is primarily aimed at treating the underlying cause, managing complications from both primary and secondary cause, supporting organ function, and stopping abnormal coagulation and controlling bleeding.
Why does menorrhagia not allow the client to rest?
2. The client’s symptoms are unrelated to the diagnosis of menorrhagia. 3. The client probably has been exposed to a virus that causes chronic fatigue. 4. Menorrhagia has caused the client to have decreased levels of hemoglobin.
How to diagnose hemolytic anemia?
1. Check on the bowel movements of a client diagnosed with melena. 2. Take the vital signs of a client who received blood the day before. 3. Evaluate the dietary intake of a client who has been noncompliant with eating. 4. Shave the client diagnosed with severe hemolytic anemia. answer.