Nokea
A 19-year-old college student reports to the health service with a sore throat, malaise, and fever of four days in duration. Examination shows cervical lymphadenopathy and splenomegaly. Temperature is 103°F. Blood is positive for heterophil antibody agglutination test. Which condition does the nurse expect this student to have?
- A. Streptococcal sore throat
- B. Infectious mononucleosis
- C. Rubella
- D. Influenza
Correct Answer: B
Rationale: The symptoms and positive heterophil antibody test are diagnostic for infectious mononucleosis.
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The nurse administers iron using the Z track technique. What is the primary reason for administering iron via Z track?
- A. To prevent adverse reactions
- B. To prevent staining of the skin
- C. To improve the absorption rate
- D. To increase the speed of onset of action
Correct Answer: B
Rationale: The Z track technique prevents iron from leaking into subcutaneous tissue, reducing skin staining.
The client diagnosed with cancer has been undergoing systemic treatments and has red blood cell deficiency. Which signs and symptoms should the nurse teach the client to manage?
- A. Nausea associated with cancer treatment.
- B. Shortness of breath and fatigue.
- C. Controlling mucositis and diarrhea.
- D. The emotional aspects of having cancer.
Correct Answer: B
Rationale: RBC deficiency (anemia) causes shortness of breath and fatigue (B), which clients should manage. Nausea (A), mucositis/diarrhea (C), and emotions (D) are unrelated to anemia.
When planning care for a client who is HIV positive, the nurse should do what?
- A. Teach persons coming in contact with the client to wear a gown and mask at all times
- B. Teach persons to wear gloves when handling any of the client's body fluids
- C. Restrict visitors to immediate family
- D. Encourage the client to stay away from other persons as much as possible
Correct Answer: B
Rationale: Wearing gloves when handling body fluids follows standard precautions to prevent HIV transmission. Gowns and masks are not always necessary, and restricting visitors or isolating the client is not required.
The client has undergone a lymph node biopsy to differentiate between Hodgkin’s and non-Hodgkin’s lymphoma. After reviewing the client’s lymph node biopsy results, which revealed that the client has Hodgkin’s lymphoma, the nurse should obtain which educational brochure?
- A. The brochure that includes an explanation of an elevated reticulocyte count
- B. The brochure that includes an explanation of CA-125 tumor markers
- C. The brochure that includes an explanation of an elevated WBC count
- D. The brochure that includes an explanation about Reed-Sternberg cells
Correct Answer: D
Rationale: A. Reticulocytes are found in a CBC, not from a lymph node biopsy, and are not indicative of either Hodgkin’s or non-Hodgkin’s lymphoma. B. CA-125 tumor markers are sometimes used in the management of ovarian cancer. C. WBCs are collected from a complete blood panel, not a lymph node biopsy, and could be indicative of other lymphomas and/or leukemia. D. The nurse should obtain the brochure that explains about Reed-Sternberg cells. The main diagnostic feature of Hodgkin’s lymphoma is the presence of Reed-Sternberg cells in a lymph node biopsy.
The client diagnosed with sickle cell anemia comes to the emergency department complaining of joint pain throughout the body. The oral temperature is 102.4°F and the pulse oximeter reading is 91%. Which action should the emergency department nurse implement first?
- A. Request arterial blood gases STAT.
- B. Administer oxygen via nasal cannula.
- C. Start an IV with an 18-gauge angiocath.
- D. Prepare to administer analgesics as ordered.
Correct Answer: B
Rationale: SpO2 91% and fever suggest hypoxia in SCA crisis; oxygen via cannula (B) addresses this first. ABGs (A), IV (C), and analgesics (D) follow to confirm hypoxia, hydrate, and manage pain.