Nokea
A home-care nurse is following up with the client who was diagnosed with liver cancer 3 months ago. Which assessment information should the nurse communicate to the HCP?
- A. Client is weak and pale and remained in bed throughout the visit
- B. Client’s weight has remained unchanged since the previous visit.
- C. Client reports itching is relieved with diphenhydramine cream.
- D. Client’s pain level averages a 7 on a 0 to 10 scale with scheduled opioids.
Correct Answer: D
Rationale: A. Finding that the client with liver cancer is weak and pale would be important to document, but it does not warrant immediate communication to the HCP because it may be expected. B. The client’s weight being stable would not necessitate communication to the HCP, but a significant decrease would. C. Abdominal itching may occur with liver cancer, but the fact that it is relieved with diphenhydramine (Benadryl) is positive and would not necessitate a call to the HCP. D. The client’s pain level is high and does not seem to be controlled with the current opioid schedule. The nurse should notify the HCP to request a change in analgesic medication, dosing schedule, or administration route.
You may also like to solve these questions
The client diagnosed with thalassemia, a hereditary anemia, is to receive a transfusion of packed RBCs. The crossmatch reveals the presence of antibodies that cannot be crossmatched. Which precaution should the nurse implement when initiating the transfusion?
- A. Start the transfusion at 10 to 15 mL/hr for 15 to 30 minutes.
- B. Re-crossmatch the blood until the antibodies are identified.
- C. Have the client sign a permit to receive uncrossmatched blood.
- D. Have the unlicensed assistive personnel stay with the client.
Correct Answer: A
Rationale: Uncrossmatched blood requires slow infusion (10–15 mL/hr) initially (A) to monitor reactions. Re-crossmatching (B) is impractical, consent (C) is for emergencies, and UAP (D) cannot monitor.
The client admitted with full-thickness burns may be developing DIC. Which signs/symptoms would support the diagnosis of DIC?
- A. Oozing blood from the IV catheter site.
- B. Sudden onset of chest pain and frothy sputum.
- C. Foul-smelling, concentrated urine.
- D. A reddened, inflamed central line catheter site.
Correct Answer: A
Rationale: DIC causes uncontrolled bleeding; oozing from IV sites (A) is a hallmark. Chest pain/sputum (B) suggests PE, urine odor (C) is unrelated, and redness (D) indicates infection.
The client diagnosed with sickle cell anemia asks the nurse, 'Should I join the Sickle Cell Foundation? I received some information from the Sickle Cell Foundation. What kind of group is it?' Which statement is the best response by the nurse?
- A. It is a foundation that deals primarily with research for a cure for SCA.'
- B. It provides information on the disease and on support groups in this area.'
- C. I recommend joining any organization that will help deal with your disease.'
- D. The foundation arranges for families that have children with sickle cell to meet.'
Correct Answer: B
Rationale: The Sickle Cell Foundation offers education and support groups (B). Research (A) is partial, generic advice (C) is vague, and family meetings (D) are not primary.
The nurse working in the bloodmobile is screening clients to determine if they qualify for blood donation of whole blood. Besides asking for identification and age, which questions should the nurse ask during the screening interview?
- A. “If you have a tattoo, on what date did you receive the tattoo?”
- B. “Have you had any close contact with anyone with HIV or hepatitis?”
- C. “If you smoke, when was the last time you smoked tobacco products?”
- D. “When were you last immunized for rubella, mumps, or varicella?”
- E. “Did you receive blood products anywhere outside of the United States?”
Correct Answer: A, B, D, E
Rationale: Persons ineligible to donate blood include those with a history of a recent tattoo. B. Persons ineligible to donate blood include those who’ve had close contact with a person with HIV or hepatitis. C. Persons who smoke tobacco products may donate blood unless they have a recent history of asthma. D. Persons ineligible to donate blood include those immunized for rubella, mumps, or varicella within the last month. E. Persons ineligible to donate blood include those receiving transfusions in the United Kingdom, Gibraltar, or the Falkland Islands because of the increased likelihood of transmitting Creutzfeldt-Jakob disease.
The nurse identified clotting as a concept related to sickle cell disease. Which intervention should the nurse implement?
- A. Assess for cerebrovascular symptoms.
- B. Keep the head of the bed elevated.
- C. Order a 2,000-mg sodium diet.
- D. Apply antiembolism stockings.
Correct Answer: A
Rationale: SCD causes vaso-occlusion; assessing cerebrovascular symptoms (A) detects stroke risk. HOB elevation (B) is for ICP, sodium diet (C) is for hypertension, and stockings (D) are for DVT.