Nokea
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.
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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 receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important?
- A. Correctly identifying client using two identifiers
- B. Double-checking client and blood type information
- C. Placing the client on strict bedrest until the pain subsides
- D. Reviewing the client's medical record for known allergies
Correct Answer: B
Rationale: This client has a hemolytic transfusion reaction, most commonly caused by blood type or Rh incompatibility. The nurse should double-check all identifying information for both the client and blood type to confirm the error. Documentation occurs after the client is stable. Bedrest may not be needed, and allergies to medications or environmental items are not related.
A nurse is preparing to administer a blood transfusion to an older adult. Understanding age-related changes, what alterations to the usual protocol are necessary for the nurse to implement? (Select all that apply.)
- A. Monitor vital signs every 15 minutes
- B. Hold other IV fluids running
- C. Premedicate to prevent reactions
- D. Transfuse each unit over 8 hours
Correct Answer: A,B
Rationale: Older adults require frequent vital sign monitoring (every 15 minutes) due to subtle signs of transfusion reactions and holding other IV fluids to prevent fluid overload. Premedication and prolonged transfusion times are not standard alterations.
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 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.