Nokea
A client who receives a diagnosis of pernicious anemia asks why she must receive vitamin shots. What is the best answer for the nurse to give?
- A. Shots work faster than pills.'
- B. Your body cannot absorb vitamin B12 from foods.'
- C. Vitamins are necessary to make the blood cells.'
- D. You can get more vitamins in a shot than a pill.'
Correct Answer: B
Rationale: In pernicious anemia, the lack of intrinsic factor prevents absorption of vitamin B12 from foods, necessitating injections.
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A college student who is diagnosed as having infectious mononucleosis asks how the disease is spread. The nurse's response is based on the knowledge that the usual mode of transmission is through:
- A. skin.
- B. genital contact.
- C. contaminated water.
- D. intimate oral contact.
Correct Answer: D
Rationale: Infectious mononucleosis, known as the 'kissing disease,' is spread through intimate oral contact, such as kissing or sharing utensils.
The nurse and the licensed practical nurse (LPN) are caring for clients on an oncology floor. Which client should not be assigned to the LPN?
- A. The client newly diagnosed with chronic lymphocytic leukemia.
- B. The client who is four (4) hours postprocedure bone marrow biopsy.
- C. The client who received two (2) units of (PRBCs) on the previous shift.
- D. The client who is receiving multiple intravenous piggyback medications.
Correct Answer: D
Rationale: IV piggyback medications (D) require complex assessment (e.g., chemotherapy), beyond LPN scope. New diagnosis (A), post-biopsy (B), and post-transfusion (C) are stable for LPN care.
The client undergoing intensive chemotherapy for Hodgkin’s lymphoma (HL) is hospitalized with fever and depressed immune system functioning. The nurse is administering filgrastim subcutaneously daily. Which laboratory value should the nurse monitor to determine the medication’s effectiveness?
- A. Hemoglobin
- B. Platelet count
- C. Absolute neutrophil count (ANC)
- D. Reed-Sternberg cells
Correct Answer: C
Rationale: A. Epoetin alfa, not filgrastim, is used to treat anemia that is associated with cancer, and its effectiveness would be reflected in the Hgb values. B. Oprelvekin (Neumega), not filgrastim, enhances the synthesis of platelets. C. The nurse should monitor the ANC. Filgrastim (Neupogen) is usually discontinued when the client’s absolute neutrophil count (ANC) is above 1000 cells/mm3. Filgrastim, a granulocyte colony-stimulating factor (G-CSF) analog, is used to stimulate the proliferation and differentiation of granulocytes and treat neutropenia. D. Reed-Sternberg cells are found in lymph node biopsy cells and are indicative of Hodgkin’s lymphoma; they are not monitored to determine the effectiveness of filgrastim, which is used to treat neutropenia.
The nurse assesses the client diagnosed with acute myeloid leukemia. Which finding should be the nurse’s priority for implementing interventions?
- A. Pain from mucositis and oral tissue injury
- B. Weakness and fatigue with slight activity
- C. T 99°F, P 100, R 22, BP 132/64 mm Hg
- D. Ecchymosis and petechiae noted on arms
Correct Answer: A
Rationale: A. Pain control is priority. The altered VS (other than temperature) could be related to pain. B. Weakness and fatigue are due to anemia and also the disease process. It is important to allow rest, but if pain is not controlled the client may not be able to rest. C. The temperature warrants further monitoring because it could indicate a developing infection; the other VS may decrease if pain is controlled. D. Ecchymosis and petechiae are associated with low platelet counts. The nurse should check the laboratory report for the platelet level, but this is an assessment and not an intervention.
Which sign/symptom will the nurse expect to assess in the client diagnosed with a vaso-occlusive sickle cell crisis?
- A. Lordosis.
- B. Epistaxis.
- C. Hematuria.
- D. Petechiae.
Correct Answer: C
Rationale: Vaso-occlusive crisis causes ischemia; hematuria (C) results from renal infarction. Lordosis (A) is spinal, epistaxis (B) is bleeding, and petechiae (D) indicate thrombocytopenia.