The nurse is caring for the patient who is 1-day status post splenectomy. The patient complains of pain of a 3 on inspiration. What would be the most appropriate priority nursing intervention for this patient?

Contact the surgeon to obtain orders for a nebulizer treatment from respiratory therapy.

Provide the patient with a heating pad alternated with a cold pack for incisional pain.

Medicate with opioids for pain and assist the patient to deep breathe, cough, and ambulate.

Contact the surgeon to request a chest x-ray and a laboratory draw for CBC with differential.

Answer and Explanation

The Correct Answer is C

A. Contact the surgeon to obtain orders for a nebulizer treatment from respiratory therapy. A nebulizer is typically not the initial intervention for mild post-operative pain or mild respiratory discomfort due to pain with inspiration.

B. Provide the patient with a heating pad alternated with a cold pack for incisional pain. While heat or cold therapy can help with pain, opioid pain management with encouragement to perform deep breathing exercises is more effective for post-splenectomy patients.

C. Medicate with opioids for pain and assist the patient to deep breathe, cough, and ambulate. Pain management combined with encouraging deep breathing, coughing, and early ambulation helps prevent post-operative complications like atelectasis and pneumonia, which are common after abdominal surgeries.

D. Contact the surgeon to request a chest x-ray and a laboratory draw for CBC with differential. This intervention might be necessary if there were signs of infection or other complications, but mild pain with inspiration on the first day post-op does not typically warrant imaging or labs.

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Correct Answer is D

Explanation

A. Malformed RBCs: Malformed RBCs are not caused by a transfusion reaction; they are generally a result of bone marrow abnormalities or genetic conditions.

B. A deficiency in vitamin B12: Vitamin B12 deficiency causes megaloblastic anemia, not hemolysis. It is unrelated to transfusion reactions.

C. An abundance of immature RBCs: Immature RBCs, or reticulocytes, can increase as a compensatory response to anemia but are not a direct result of a transfusion reaction. The primary issue is RBC destruction.

D. Destruction of RBCs: A hemolytic reaction occurs when the immune system attacks incompatible red blood cells, leading to their destruction.

A. Myxedema B. Pathologic fracture C. Retinopathy D. Gastrointestinal bleeding

Correct Answer is B

Explanation

A. Myxedema: Myxedema is associated with hypothyroidism, not multiple myeloma.

B. Pathologic fracture: Advanced multiple myeloma causes bone demineralization and osteolytic lesions, making bones fragile and increasing the risk for pathologic fractures.

C. Retinopathy: Retinopathy is commonly associated with diabetes or hypertension, not with multiple myeloma.

D. Gastrointestinal bleeding: Gastrointestinal bleeding is not a typical complication of multiple myeloma.

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The nurse is caring for the patient who is 1-day status post splenectomy. The patient complains of pain of a 3 on inspiration. What would be the most appropriate priority nursing intervention for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient receiving treatment for a hemolytic reaction from a mismatched blood transfusion. The nurse understands that this the incompatible blood is causing what?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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