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A 16-year-old patient with a left-side pelvic osteosarcoma is taking extended release oxycodone twice daily as well as immediate release oxycodone for breakthrough pain approximately 2 or 3 times per day. She describes her pain as burning, tingling, and shooting in her left leg. Her pain worsens with hot showers. Her most recent EKG has a QTc of 495. What would be the best strategy to manage her pain?
- A. Switch from long-acting oxycodone to methadone.
- B. Recommend more frequent use of her immediate release oxycodone.
- C. Add amitriptyline daily. Start low and titrate upward on dosage.
- D. Add gabapentin three times daily. Start low and titrate upward on dose.
Correct Answer: D
Rationale: Step 1: The patient's pain is described as burning, tingling, and shooting in her left leg, which suggests neuropathic pain.
Step 2: The pain worsens with hot showers, indicating sensitivity to temperature changes, a common feature of neuropathic pain.
Step 3: Gabapentin is a first-line medication for neuropathic pain, as it stabilizes nerve cells and reduces abnormal pain signaling.
Step 4: Starting low and titrating upward on gabapentin dose helps minimize side effects and optimize pain relief.
Step 5: Methadone (Choice A) is not the best option for neuropathic pain. Increasing immediate release oxycodone (Choice B) may lead to opioid tolerance. Amitriptyline (Choice C) may help neuropathic pain but is not as specific as gabapentin.
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A nurse is caring for a client who is taking clopidogrel to prevent stent restenosis. The nurse should monitor the client for which of the following adverse reactions?
- A. Hyperuricemia
- B. Hyponatremia
- C. Lymphocytopenia
- D. Thrombocytopenia
Correct Answer: D
Rationale: The correct answer is D: Thrombocytopenia. Clopidogrel is an antiplatelet medication that works by preventing blood clots. Thrombocytopenia is a decrease in platelet count, which can lead to bleeding issues. Monitoring for thrombocytopenia is essential as it can be a potential adverse reaction of clopidogrel.
A: Hyperuricemia is not typically associated with clopidogrel.
B: Hyponatremia is not a common adverse reaction of clopidogrel.
C: Lymphocytopenia is not a common side effect of clopidogrel.
In summary, the nurse should monitor for thrombocytopenia as a potential adverse reaction when caring for a client taking clopidogrel.
A 10-year-old patient with aplastic anemia, who is blood type B negative, is receiving a red blood cell transfusion. About 10 minutes after the transfusion starts, the patient develops anxiety and lower back pain. The transfusion continues for another 5 minutes until it is stopped when he develops a temperature of 40 °C with chills and rigors. A transfusion reaction work-up is most likely to reveal what findings?
- A. Spherocytes on peripheral blood smear
- B. Gram-negative Bacillus on gram stain of remaining RBC unit
- C. Chest x-ray with bilateral pulmonary infiltrates that are new compared to an x-ray done last week
- D. DAT positive for C3
Correct Answer: D
Rationale: The correct answer is D: DAT positive for C3. This finding suggests complement-mediated hemolysis, which is consistent with a transfusion reaction known as transfusion-related acute lung injury (TRALI). TRALI presents with respiratory distress, fever, and chills due to immune complexes activating the complement system. A: Spherocytes indicate hemolysis, which is not specific to TRALI. B: Gram-negative Bacillus suggests bacterial contamination, leading to sepsis, not TRALI. C: Bilateral pulmonary infiltrates are seen in transfusion-associated circulatory overload (TACO), not TRALI.
You are treating a patient with localized osteosarcoma of the distal femur with methotrexate, doxorubicin, and cisplatin (MAP) chemotherapy. At week 10 of treatment, the patient undergoes complete resection of the tumor. Pathology demonstrates 40% necrosis. Which of the following represents the most appropriate further therapy?
- A. Ifosfamide and etoposide (IE)
- B. MAP plus ifosfamide and etoposide (MAPIE)
- C. Gemcitabine docetaxel
- D. MAP
Correct Answer: D
Rationale: The correct answer is D: MAP. In localized osteosarcoma, the response to preoperative chemotherapy is evaluated based on the percentage of tumor necrosis. A necrosis of 40% is considered a good response. The standard of care after surgery is to continue with the same chemotherapy regimen to complete the course. Continuing with MAP in this case is important to ensure that any remaining cancer cells are effectively treated. Option A (IE) and option B (MAPIE) are not indicated as they are different regimens and not the standard of care for this scenario. Option C (Gemcitabine docetaxel) is also not the appropriate choice as it is not the standard treatment protocol for localized osteosarcoma.
A 72-year-old male with enlargement of superficial lymph nodes and mild hepatosplenomegaly is diagnosed as having chronic lymphatic leukemia (CLL). The most important criteria for diagnosis of this disease is the
- A. Presence of hypogammaglobulinemia
- B. Absolute lymphocytes
- C. Male predominance
- D. Presence of enlarged lymph nodes
Correct Answer: B
Rationale: The correct answer is B: Absolute lymphocytes. In CLL, the most important diagnostic criteria is an absolute lymphocyte count greater than 5,000/microliter. This is crucial for distinguishing CLL from other lymphoproliferative disorders. The presence of hypogammaglobulinemia (choice A) is not specific to CLL and can be seen in other conditions. Male predominance (choice C) is an epidemiological feature and not a diagnostic criterion. Enlarged lymph nodes (choice D) are a common clinical finding but do not solely confirm the diagnosis of CLL.
Which of the following is false regarding heparin?
- A. Subcutaneous injection of heparin is avoided because of hematomas formation.
- B. Heparin is usually stored in the mast cells.
- C. Heparin binds to plasma anti thrombin III and inhibits activated thrombin.
- D. Protamine sulfate can be used to counteract heparin overdose.
Correct Answer: A
Rationale: Step-by-step rationale:
1. Subcutaneous injection of heparin is avoided due to the risk of hematoma formation at the injection site.
2. This statement is false because heparin is commonly administered subcutaneously for prophylaxis of thromboembolic events.
3. The preferred route for heparin administration is subcutaneous or intravenous.
4. Therefore, choice A is the false statement.
Summary:
- Choice A is incorrect as heparin is commonly given subcutaneously.
- Choice B is incorrect as heparin is not stored in mast cells but in specialized granules in mast cells.
- Choice C is correct as heparin binds to plasma antithrombin III to inhibit thrombin.
- Choice D is correct as protamine sulfate can reverse heparin's anticoagulant effects in case of overdose.