Nokea
The young adult, diagnosed with hemophilia A, is receiving a monthly scheduled dose of factor VIII cryoprecipitate. The client begins to cry during administration. Which response by the nurse is most appropriate?
- A. “Why are you crying? You seem afraid when I am administering the drug.”
- B. “Is it painful while I’m giving this IV push? If so, I can give it by infusion.”
- C. “I know this is uncomfortable for you; this only takes a few minutes to give.”
- D. “If you want to talk to me about what you are feeling, I am here to listen.”
Correct Answer: D
Rationale: A. Asking a “why” question challenges the client’s feelings. B. This response seeks information but is not most appropriate. It is unlikely that the initial response from an adult would not be crying if the administration of IV factor VIII cryoprecipitate by IV push were painful. C. This response ignores the client’s feelings and presumes that the nurse knows what initiated the client’s crying. D. The nurse is offering self, which is a therapeutic communication technique.
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The nurse is administering vesicant chemotherapy medications such as doxorubicin hydrochloride to clients. Which nursing actions should the nurse implement to prevent extravasation?
- A. Give through an IV catheter in a large peripheral vein if infusing in less than 60 minutes.
- B. Check patency every 5 to 10 minutes during infusion and ask about IV site discomfort.
- C. Check the IV pump and alarm for indications of an infiltration of the medication.
- D. Check for blood return in a central venous catheter prior to administration of the vesicant.
- E. Use small-gauged syringes with small barrels when flushing any access devices with saline.
Correct Answer: A, B, D
Rationale: A peripheral IV catheter may be used for a vesicant if administration time is less than 60 minutes, a large vein is used, and there is careful monitoring of the IV site. B. Checking for patency and asking about discomfort at the IV site will help prevent an infiltration. C. IV pumps and alarms cannot be relied upon to detect extravasation because infiltration usually does not cause sufficient pressure to trigger an alarm. D. Checking for blood return in the central venous catheter prior to administration will help ensure that the medication is being administered into a vessel and not into tissues. E. Small-gauge syringes with small barrels produce high pressures and may cause injury to the blood vessel or may damage a central line catheter and should not be used.
The client is diagnosed with hereditary spherocytosis. Which treatment/procedure would the nurse prepare the client to receive?
- A. Bone marrow transplant.
- B. Splenectomy.
- C. Frequent blood transfusions.
- D. Liver biopsy.
Correct Answer: B
Rationale: Spherocytosis causes hemolytic anemia; splenectomy (B) reduces RBC destruction. BMT (A) is for leukemia, transfusions (C) are supportive, and liver biopsy (D) is unrelated.
The nurse is caring for a client in a sickle cell crisis. Which is the pain regimen of choice to relieve the pain?
- A. Frequent aspirin (acetylsalicylic acid) and a nonnarcotic analgesic.
- B. Motrin (ibuprofen), a nonsteroidal anti-inflammatory drug (NSAID), prn.
- C. Demerol (meperidine), a narcotic analgesic, every four (4) hours.
- D. Morphine, a narcotic analgesic, every two (2) to three (3) hours prn.
Correct Answer: D
Rationale: Morphine PRN (D) is preferred for severe SCA crisis pain, titrated to relief. Aspirin (A) and ibuprofen (B) are insufficient and risk bleeding, and meperidine (C) risks seizures.
An elderly client who is being treated for pernicious anemia needs to be monitored periodically for which of the following conditions?
- A. Lactose intolerance
- B. Stomach cancer
- C. Dementia
- D. Hearing loss
Correct Answer: B
Rationale: Pernicious anemia is associated with an increased risk of stomach cancer due to chronic gastritis, requiring periodic monitoring.
The nurse is discussing dietary sources of iron with a client who has iron deficiency anemia. Which menu, if selected by the client, indicates the best understanding of the diet?
- A. Milkshake, hot dog, and beets
- B. Beef steak, spinach, and grape juice
- C. Chicken salad, green peas, and coffee
- D. Macaroni and cheese, coleslaw, and lemonade
Correct Answer: B
Rationale: Beef, spinach, and grape juice contain iron. Milk contains no iron, and the other options have lower iron content.