Nokea
A charge nurse is teaching a newly licensed nurse about risk factors for chronic myelogenous leukemia (CML). Which of the following information should the nurse include?
- A. Exposure to radiation
- B. Family history
- C. Another type of cancer
- D. Genetic mutation
Correct Answer: A
Rationale: Exposure to high levels of radiation is a known risk factor for CML, as seen in historical data from atomic bomb survivors. Family history and other cancers are not significant risk factors, and the Philadelphia chromosome mutation is an acquired, not inherited, genetic factor.
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A nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first?
- A. Elevate the limb and apply ice.
- B. Apply a tourniquet just below the elbow.
- C. Apply direct pressure over the wound.
- D. Clean the wound.
Correct Answer: C
Rationale: Applying direct pressure is the first-line intervention to control profuse bleeding, stopping or reducing blood loss immediately.
A nurse is caring for a client who has sickle cell anemia. The client asks, 'Why do I feel so tired and fatigued all of the time?' Which of the following information should the nurse provide?
- A. You have had a gastrointestinal bleed.
- B. You have a low ferritin level.
- C. You have an autoimmune disease.
- D. You have fewer red blood cells.
Correct Answer: D
Rationale: Sickle cell anemia causes fewer healthy red blood cells due to fragile sickled cells, leading to anemia and reduced oxygen delivery, causing fatigue.
A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?
- A. Sleep on the abdomen to facilitate wound healing.
- B. Bend at the waist to pick objects up from the floor.
- C. Notify the surgeon if white drainage develops on the eyelids.
- D. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
Correct Answer: D
Rationale: Lifting heavy objects can increase intraocular pressure, disrupting healing post-cataract surgery. Avoiding heavy lifting is critical. Other options risk complications or are unnecessary.
A nurse is obtaining a health history from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?
- A. Slurred speech
- B. Confusion
- C. Pain
- D. Fatigue
Correct Answer: D
Rationale: Fatigue is a hallmark symptom of iron deficiency anemia due to decreased oxygen-carrying capacity of the blood, leading to tiredness and lack of energy. Slurred speech, confusion, and pain are not typical symptoms unless associated with severe or advanced stages.
A nurse is providing teaching to a group of clients about the changes that occur in the eye when clients experience retinal detachment. Which of the following statements should the nurse include in the teaching?
- A. Vision changes occur suddenly due to complete obstruction of aqueous humor outflow
- B. Vision changes occur when retinal tissue pulls away from the blood vessels in the eye
- C. Vision changes occur when the retina begins to breakdown and collect bits of debris
- D. Vision changes occur when the cloudy lens alters the passage of light through the eye
Correct Answer: B
Rationale: Retinal detachment occurs when the retina separates from its supporting tissues and blood vessels, leading to vision loss. Other options describe different eye conditions like glaucoma, macular degeneration, or cataracts.