Nokea
A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the client?
- A. Apply ice packs to the client's legs.
- B. Elevate the client's legs on pillows.
- C. Keep the lower extremities warm.
- D. Place elastic bandage wraps on the client's legs.
Correct Answer: C
Rationale: During a sickle cell crisis, the tissue distal to the occlusion has decreased blood flow and ischemia, leading to pain. Keeping the legs warm helps improve comfort due to decreased blood flow causing coolness. Elevation or elastic bandages may further reduce perfusion, and ice packs are not indicated.
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A nurse is caring for four clients with leukemia. After hand-off report, which client should the nurse see first?
- A. Client who had two bloody diarrhea stools this morning
- B. Client who has been premedicated for nausea prior to chemotherapy
- C. Client with a respiratory rate change from 18 to 22 breaths/min
- D. Client with an unchanged lesion to the lower right lateral malleolus
Correct Answer: A
Rationale: The client with two bloody diarrhea stools may be hemorrhaging in the gastrointestinal tract, indicating a potentially life-threatening condition requiring immediate assessment. The client with a respiratory rate change may have an infection or worsening anemia and should be seen next. The other two clients are not as urgent.
A client has frequent hospitalizations for leukemia and is worried about functioning as a parent to four small children. What action by the nurse would be most helpful?
- A. Assist the client to make sick day plans for household responsibilities.
- B. Help the client inform friends and family that they will have to help out.
- C. Refer the client to a social worker for family counseling.
- D. Provide information on community support groups.
Correct Answer: A
Rationale: Helping the client make sick day plans addresses their concern about parenting responsibilities during hospitalizations, offering practical support. Informing friends and family is less proactive, and while counseling or support groups may help, they are less immediate solutions.
A client with sickle cell disease (SCD) takes hydroxyurea (Droxia). The client presents to the clinic reporting an increase in fatigue. What laboratory result should the nurse report immediately?
- A. Hematocrit: 25%
- B. Hemoglobin: 2.2 mg/dL
- C. Potassium: 3.2 mEq/L
- D. White blood cell count: 38,000/mm3
Correct Answer: D
Rationale: Although individuals with SCD often have elevated white blood cell counts, an extreme elevation like 38,000/mm3 could indicate leukemia, a serious complication of hydroxyurea, or a severe infection, both critical in SCD patients. Hematocrit and hemoglobin levels are typically low in SCD, and the potassium level, while slightly low, is less urgent.
A client has heparin-induced thrombocytopenia (HIT). The student nurse asks how this is treated. About what drugs does the nurse instructor teach? (Select all that apply.)
- A. Argatroban (Argatroban)
- B. Bivalirudin (Angiomax)
- C. Clopidogrel (Plavix)
- D. Lepirudin (Refludan)
- E. Methylprednisolone (Solu-Medrol)
Correct Answer: A,B,D
Rationale: Argatroban, bivalirudin, and lepirudin are direct thrombin inhibitors used to treat HIT. Clopidogrel is an antiplatelet agent, and methylprednisolone is a steroid, neither used for HIT.
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.