Nokea
A client has been admitted after sustaining a humerus fracture that occurred when picking up the family cat. What test result would the nurse correlate to this condition?
- A. Bence-Jones protein in urine
- B. Epstein-Barr virus positive
- C. Hemoglobin: 18 mg/dL
- D. Red blood cell count 8.2/mm3
Correct Answer: A
Rationale: This client has possible multiple myeloma. A positive Bence-Jones protein finding would correlate with this condition. The Epstein-Barr virus is associated with infectious mononucleosis and some cancers, not directly with multiple myeloma. Hemoglobin of meaningful correlation. Similarly, a red blood cell count of 8.2/mm3 is high but requires further information for specific correlation.
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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.
A nurse working with clients with sickle cell disease (SCD) teaches about self-management to prevent exacerbation and sickle cell crises. What factors should clients be taught to avoid? (Select all that apply.)
- A. Dehydration
- B. Radiation
- C. Extreme stress
- D. High altitudes
- E. Pregnancy
Correct Answer: A,C,D,E
Rationale: Several factors cause red blood cells to sickle in SCD, including dehydration, extreme stress, high altitudes, and pregnancy, as they can trigger vaso-occlusive crises. Radiation is not a specific trigger unless related to extreme physical stress.
A nurse is preparing to administer a blood transfusion. What action is most important?
- A. Correctly identifying client using two identifiers
- B. Obtaining informed consent
- C. Placing the blood product with Ringer's lactate
- D. Staying with the client for the entire transfusion
Correct Answer: B
Rationale: Obtaining informed consent is critical as it ensures the client understands the procedure and risks, which is a priority before initiating a transfusion. Correctly identifying the client is also crucial but follows consent in priority if the facility requires it. Ringer's lactate is not used for blood transfusions, and staying for the entire transfusion is not necessary.
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.
The nurse assesses a client's oral cavity and makes the discovery shown in the photo below: What action by the nurse is most appropriate?
- A. Encourage the client to have genetic testing
- B. Instruct the client on high-fiber foods
- C. Place the client in neutropenic precautions
- D. Teach the client about cobalamin therapy
Correct Answer: D
Rationale: The condition shown is glossitis, characteristic of B12 deficiency anemia, treated with cobalamin (vitamin B12). Genetic testing, high-fiber foods, or neutropenic precautions are not relevant to this condition.