Nokea
A child who is being treated for leukemia develops stomatitis. Which of the following nursing care measures is essential?
- A. Using dental floss to clean the teeth
- B. Frequent cleaning of the mouth with an astringent mouthwash
- C. Use of an overbed cradle
- D. Swabbing the mouth with moistened cotton swabs
Correct Answer: D
Rationale: Swabbing the mouth with moistened cotton swabs gently cleans the mouth without irritating stomatitis. Flossing or astringent mouthwash may worsen irritation, and an overbed cradle is unrelated.
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The client has a blood type of B negative. The client’s family asks if they can donate blood for the client. The nurse informs the family that they would need to be of which blood type to be considered for a directed donation of RBCs for this client?
- A. Type A positive
- B. Type B positive
- C. Type B negative
- D. Type O positive
- E. Type O negative
- F. Type AB positive
Correct Answer: C, E, A
Rationale: Blood type A positive has the D antigen on the RBC, making it incompatible with blood type B negative. B. Blood type B positive has the D antigen on the RBC, making it incompatible with blood type B negative. C. The client with B negative blood type has B antigen on the RBC and does not have an Rh (or D) antigen on the cell. Because the client can receive RBCs of the same blood type, a person with type B negative blood could be considered for a directed donation. D. Blood type O positive has the D antigen, making it incompatible with blood type B negative. E. Type O negative has no antigens on the RBC so a directed donation from a person with type O negative blood could also be considered. F. Blood type AB positive has the D antigen on the RBC, making it incompatible with blood type B negative.
Laboratory tests are prescribed for the client who has a smooth and reddened tongue and ulcers at the corners of the mouth. Which result would the nurse find if the client has iron-deficiency anemia?
- A. Low hemoglobin and hematocrit
- B. Elevated red blood cells (RBCs)
- C. Prolonged prothrombin time (PT)
- D. Elevated white blood cells (WBCs)
Correct Answer: A
Rationale: A. A smooth, red tongue, ulcers at the corners of the mouth (angular cheilosis), and a low Hgb are signs of iron-deficiency anemia. B. Excess RBCs are associated with polycythemia vera. C. Prolonged PT is seen with clients taking antico-agulants or experiencing a coagulation disorder. D. Elevated WBCs are not associated with iron-deficiency anemia but with an infection. Ulcers, if infected, would elevate the WBCs.
The nurse is caring for a client diagnosed with sickle cell disease. Which should the nurse include in the client’s plan of care?
- A. Teach the client to limit fluids.
- B. Discuss interventions to maintain hydration.
- C. Measure the client’s calf for swelling.
- D. Have the client take narcotic pain medication every four (4) hours.
Correct Answer: B
Rationale: Hydration (B) prevents sickling in SCD. Limiting fluids (A) worsens crisis, calf swelling (C) is for DVT, and scheduled narcotics (D) risk dependency.
The nurse is administering a transfusion of packed red blood cells to a client. Which interventions should the nurse implement? List in order of performance.
- A. Start the transfusion slowly.
- B. Have the client sign a permit.
- C. Assess the IV site for size and patency.
- D. Check the blood with another nurse at the bedside.
- E. Obtain the blood from the laboratory.
Correct Answer: E,C,B,D,A
Rationale: 1. Obtain blood (E): Retrieve from lab. 2. Assess IV site (C): Ensure 18-gauge patency. 3. Sign permit (B): Obtain consent. 4. Check blood (D): Verify with another nurse. 5. Start slowly (A): Infuse at 10–15 mL/hr initially.
The new nurse requests information about chronic lymphocytic leukemia (CLL). Which statements should an experienced nurse include?
- A. CLL is a malignancy of activated B lymphocytes.
- B. CLL is the most common malignancy of older adults.
- C. CLL is unresponsive to chemotherapy treatment.
- D. Clients are monitored in its early stages and often not treated.
- E. In CLL immature lymphocytes accumulate in the bone marrow.
- F. Clients with CLL often have no symptoms of the disorder.
Correct Answer: A, B, D, F
Rationale: CLL derives from a malignant clone of B lymphocytes. T-lymphocytic CLL is rare. B. Two-thirds of all persons with CLL are older than 60 years at diagnosis. C. Treatment for CLL includes chemotherapy with fludarabine (Fludara), but a major side effect is prolonged bone marrow suppression. D. Clients with CLL are monitored, and treatment is initiated when symptoms are severe (night sweats, painful lymphadenopathy) or the disease progresses to later stages. E. In CLL there is an accumulation of mature-appearing but functionally inactive lymphocytes, and not immature lymphocytes. Excessive accumulation of immature lymphocytes occurs in ALL. F. Because many persons are asymptomatic, it is often diagnosed during a routine physical or during treatment for another condition.