Nokea
A child with leukemia bruises easily. This is most likely due to which of the following?
- A. Decreased fibrinogen levels
- B. Excessive clotting elsewhere in the body
- C. Decreased platelets
- D. Decreased erythrocytes
Correct Answer: C
Rationale: Leukemia causes bone marrow failure, leading to decreased platelets, which results in easy bruising.
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An elderly client who is being treated for pernicious anemia needs to be monitored periodically for which of the following conditions?
- A. Lactose intolerance
- B. Stomach cancer
- C. Dementia
- D. Hearing loss
Correct Answer: B
Rationale: Pernicious anemia is associated with an increased risk of stomach cancer due to chronic gastritis, requiring periodic monitoring.
The nurse is administering vesicant chemotherapy medications such as doxorubicin hydrochloride to clients. Which nursing actions should the nurse implement to prevent extravasation?
- A. Give through an IV catheter in a large peripheral vein if infusing in less than 60 minutes.
- B. Check patency every 5 to 10 minutes during infusion and ask about IV site discomfort.
- C. Check the IV pump and alarm for indications of an infiltration of the medication.
- D. Check for blood return in a central venous catheter prior to administration of the vesicant.
- E. Use small-gauged syringes with small barrels when flushing any access devices with saline.
Correct Answer: A, B, D
Rationale: A peripheral IV catheter may be used for a vesicant if administration time is less than 60 minutes, a large vein is used, and there is careful monitoring of the IV site. B. Checking for patency and asking about discomfort at the IV site will help prevent an infiltration. C. IV pumps and alarms cannot be relied upon to detect extravasation because infiltration usually does not cause sufficient pressure to trigger an alarm. D. Checking for blood return in the central venous catheter prior to administration will help ensure that the medication is being administered into a vessel and not into tissues. E. Small-gauge syringes with small barrels produce high pressures and may cause injury to the blood vessel or may damage a central line catheter and should not be used.
Following morning shift report, the nurse identifies care needs for four clients. Which client should be the nurse’s priority?
- A. The client with lung cancer who is to receive ondansetron 8 mg IV 30 minutes prior to chemotherapy
- B. The client with an absolute neutrophil count of 98/mm3 who needs to be placed on neutropenic precautions
- C. The client who is stable but has breast cancer and is scheduled for external beam radiation in 15 minutes
- D. The client with stomatitis from radiation for tonsillar cancer who is to receive a gastrostomy tube feeding
Correct Answer: B
Rationale: A. No time is noted for the administration of ondansetron (Zofran) prior to chemotherapy treatment; this client is not the nurse’s priority. B. The client with neutropenia should be the nurse’s priority. If seen first, microorganisms from other clients would be less likely to be transmitted to the client. This client is at risk for infection and severe sepsis because the absolute neutrophil count is less than 1001mm3 (normal = 1500 to 8000/mm3). C. This client is stable; another person can take this client to radiation therapy, and the nurse’s assessment can wait until the client returns. D. The tube feeding can be initiated after the needs of the most critical client are met.
The client diagnosed with anemia has an Hb of 6.1 g/dL. Which complication should the nurse assess for?
- A. Decreased pulmonary functioning.
- B. Impaired muscle functioning.
- C. Congestive heart failure.
- D. Altered gastric secretions.
Correct Answer: C
Rationale: Severe anemia (Hb 6.1) reduces oxygen delivery, straining the heart and risking CHF (C). Pulmonary (A), muscle (B), and gastric (D) issues are less direct.
The client is being admitted with folic acid deficiency anemia. Which would be the most appropriate referral?
- A. Alcoholics Anonymous.
- B. Leukemia Society of America.
- C. A hematologist.
- D. A social worker.
Correct Answer: C
Rationale: Folic acid deficiency anemia requires a hematologist (C) for evaluation/treatment. AA (A) is for alcoholism, Leukemia Society (B) is unrelated, and social work (D) is secondary.