Nokea
A client has thrombocytopenia. What client statement indicates the client understands self-management of this condition?
- A. I brush and use dental floss every day.
- B. I chew hard candy for my dry mouth.
- C. I usually put ice on bumps or bruises.
- D. Nonslip socks are best when I walk.
Correct Answer: C
Rationale: The client should be taught to apply ice to areas of minor trauma to reduce bleeding risk. Flossing is not recommended due to the risk of gum bleeding. Hard foods should be avoided to prevent injury, and while nonslip socks promote safety, they do not directly address thrombocytopenia management.
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A client has Hodgkin's lymphoma, Ann Arbor stage Ib. For what manifestations should the nurse assess the client? (Select all that apply.)
- A. Headaches
- B. Night sweats
- C. Persistent fever
- D. Urinary frequency
- E. Weight loss
Correct Answer: B,C,E
Rationale: In Ann Arbor stage Ib, Hodgkin's lymphoma may present with systemic symptoms like night sweats, persistent fever, and weight loss, known as B symptoms. Headaches and urinary frequency are not typical manifestations of this stage.
A nurse is caring for a young male client with lymphoma who is to begin treatment. What teaching topic is a priority?
- A. Genetic testing
- B. Sperm banking
- C. Treatment options
- D. Lifestyle changes
Correct Answer: B
Rationale: All teaching topics are important to the client with lymphoma, but for a young male, sperm banking is of appropriate concern if the client is going to have radiation to the lower abdomen or pelvis.
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 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 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.