Nokea
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.
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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.
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 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 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 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.