Nokea
A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse?
- A. Inform the client that the position must be changed, and then you will give her pain medication and omit the bath.
- B. Inform the client that she will feel better after receiving a bath and clean sheets.
- C. Obtain the pain medication and delay the bath and position change until the medication reaches its peak.
- D. Inform the client that the bath and positioning is an important part of client care and will be done right after pain medication administration.
Correct Answer: C
Rationale: When pain is severe, the nurse delays position changes and bathing until an administered analgesic has reached its peak concentration level and the client is experiencing maximum pain relief. Pain medication should never be delayed to assist in the control of the level of pain. Pain will not be relieved by a bath and clean sheets, only analgesics at this point in the client's illness.
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A teenaged client with hemophilia sustains a leg laceration after falling off a skateboard and is brought to the emergency department. The laceration is bleeding profusely even with direct pressure to the site. What does the nurse anticipate will be prescribed for administration to control bleeding?
- A. Fresh frozen plasma
- B. A colloid solution such as hetastarch (Hespan)
- C. A crystalloid solution such as lactated Ringer's
- D. Albumin
Correct Answer: A
Rationale: Treatment includes transfusion of fresh blood, frozen plasma, factor VIII concentrate, and anti-inhibitor coagulant complex for hemophilia A, factor IX concentrate for hemophilia B, factor XI for hemophilia C, and the application of thrombin or fibrin to the bleeding area. Other measures used to help control bleeding are the administration of fresh frozen plasma, aminocaproic acid that helps to hold a clot in place once it has formed, direct pressure over the bleeding site, and cold compresses or ice packs. Hetastarch, lactated Ringer's, or albumin will not control the bleeding related to hemophilia.
The nurse is collecting data for a client who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia?
- A. I feel hot all of the time.
- B. I have a difficult time falling asleep at night.
- C. I have an increase in my appetite.
Correct Answer: D
Rationale: Most clients with iron-deficiency anemia have reduced energy, feel cold all the time, and experience fatigue and dyspnea with minor physical exertion. The heart rate usually is rapid even at rest. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased. The client would feel cold and not hot. The client is fatigued and able to sleep often with a decrease in appetite, not an increase.
A client is being treated in the hospital for hypovolemia related to a bleeding peptic ulcer. The nurse obtains a blood pressure reading of 88/62 mm Hg, heart rate of 112 beats/minute, and a respiratory rate of 24 breaths/minute. What is the first action by the nurse?
- A. Administer blood.
- B. Notify the physician.
- C. Insert two large-bore intravenous catheters.
- D. Administer a colloid solution.
Correct Answer: B
Rationale: A systolic blood pressure below 90 mm Hg and heart rate above 100 beats/minute should be reported immediately. Administering blood, inserting two large-bore IV catheters, and administration of a colloid solution should be performed only with a physician's prescription and may not be required at this time.
A client who is diagnosed multiple myeloma experiences decreased production of red blood cells (RBCs). Which prescribed medication should the nurse prepare to administer to increase the production of erythrocytes?
- A. Filgrastim
- B. Pegfilgrastim
- C. Erythropoietin
- D. Dexamethasone
Correct Answer: C
Rationale: The medication erythropoietin can be used to stimulate the production of red blood cells; therefore, this is the prescribed medication that the nurse prepares to administer to the client. Filgrastim and pegfilgrastim promote proliferation of neutrophils, not erythrocytes. Dexamethasone is a corticosteroid that is prescribed for clients who are diagnosed with multiple myeloma to inhibit the inflammatory immune response.
A client is experiencing chronic hypovolemic anemia as evidenced by laboratory results. What symptoms does the nurse expect to find for this client when collecting objective data?
- A. Postural hypotension
- B. Urinary output of 10 mL/hr
- C. Altered consciousness
- D. Extreme pallor
Correct Answer: A
Rationale: Symptoms of chronic hypovolemic anemia include pallor, fatigue, chills, postural hypotension, and rapid heart rate and respiratory rates. The symptom of decreased urinary output, altered consciousness, and extreme pallor are all signs of acute hypovolemic anemia from severe blood loss. These signs indicate hypovolemic shock.