Nokea
A client admitted for sickle cell crisis is distraught after learning her child also has the disease. What response by the nurse is best?
- A. Both you and the father are equally responsible for passing it on.
- B. I can see you are upset. I can stay here with you a while if you like.
- C. I am sorry you have to go through this. I will be here to help you.
- D. There are many good treatments for sickle cell disease these days.
Correct Answer: B
Rationale: The best response is for the nurse to offer self, a therapeutic communication technique that uses presence to provide emotional support. Assigning blame or focusing on treatments does not address the client's emotional distress, and while offering help is supportive, staying with the client is the most immediate and effective response.
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A client has received a bone marrow transplant and is waiting for engraftment. What actions by the nurse are most appropriate? (Select all that apply.)
- A. Not allowing any visitors until engraftment
- B. Limiting the protein in the client's diet
- C. Having the client wear a mask
- D. Teaching visitors appropriate hand hygiene
- E. Telling visitors not to bring live flowers or plants
Correct Answer: C,D,E
Rationale: Clients awaiting engraftment are immunocompromised, requiring protective precautions like wearing a mask, strict hand hygiene for visitors, and avoiding fresh flowers or plants due to infection risks. Limiting protein is not beneficial, and completely barring visitors is overly restrictive.
A nurse caring for a client with sickle cell disease (SCD) reviews the clients laboratory work. Which finding should the nurse reports to the provider?
- A. Creatinine: 2.9 mg/dL
- B. Hemlacture: 30.9%
- C. Sodium: 147 mEq/L
- D. White blood cell count: 12,000/mm3
Correct Answer: A
Rationale: An elevated creatinine indicates kidney damage, which occurs in SCD. A hematocrit level of 30.9% is an expected finding, as is a slightly elevated white blood cell count. A sodium level of 147 mEq/L, although slightly high, is not concerning.
A nurse is preparing to hang a blood transfusion. Which action is most important?
- A. Documenting the transfusion
- B. Placing the client in NPO status
- C. Checking the blood product label
- D. Putting on a pair of gloves
Correct Answer: D
Rationale: To prevent bloodborne illness, the nurse should don a pair of gloves prior to hanging the blood, prioritizing infection control. Documentation is important but not the priority at this point. NPO status is not required, and checking the blood product label, while critical, is secondary to standard precautions like wearing gloves.
The nurse instructor is best?
- A. Because of immunosuppression, the donor cells take over.
- B. In like a transfusion reaction because no perfect matches exist.
- C. The client's cells are fighting donor cells for dominance.
- D. The donor's cells are actually attacking the client's cells.
Correct Answer: D
Rationale: Graft versus host disease is an autoimmune-type process in which the donor cells recognize the client's cells as foreign and begin attacking them. The other answers are not accurate.
A client with multiple myeloma demonstrates worsening bone density on diagnostic scans. About what drug does the nurse plan to teach this client?
- A. Zoledronic acid (Zometa)
- B. Denosumab (Xgeva)
- C. Bortezomib (Velcade)
- D. Lenalidomide (Revlimid)
Correct Answer: A
Rationale: Zoledronic acid is a bisphosphonate commonly used to treat bone loss in multiple myeloma by inhibiting osteoclast activity, thus improving bone density. Denosumab is another option for bone health but is less commonly used in this context. Bortezomib and lenalidomide are used for treating multiple myeloma but primarily target the cancer cells, not specifically bone density.