Nokea
A home-care nurse is following up with the client who was diagnosed with liver cancer 3 months ago. Which assessment information should the nurse communicate to the HCP?
- A. Client is weak and pale and remained in bed throughout the visit
- B. Client’s weight has remained unchanged since the previous visit.
- C. Client reports itching is relieved with diphenhydramine cream.
- D. Client’s pain level averages a 7 on a 0 to 10 scale with scheduled opioids.
Correct Answer: D
Rationale: A. Finding that the client with liver cancer is weak and pale would be important to document, but it does not warrant immediate communication to the HCP because it may be expected. B. The client’s weight being stable would not necessitate communication to the HCP, but a significant decrease would. C. Abdominal itching may occur with liver cancer, but the fact that it is relieved with diphenhydramine (Benadryl) is positive and would not necessitate a call to the HCP. D. The client’s pain level is high and does not seem to be controlled with the current opioid schedule. The nurse should notify the HCP to request a change in analgesic medication, dosing schedule, or administration route.
You may also like to solve these questions
The client receiving a unit of PRBCs begins to chill and develops hives. Which action should be the nurse’s first response?
- A. Notify the laboratory and health-care provider.
- B. Administer the histamine-1 blocker, Benadryl, IV.
- C. Assess the client for further complications.
- D. Stop the transfusion and change the tubing at the hub.
Correct Answer: D
Rationale: Chills/hives suggest a transfusion reaction; stopping the transfusion at the hub (D) prevents further reaction. Assessment (C), Benadryl (B), and notification (A) follow.
The client diagnosed with sickle cell anemia comes to the emergency department complaining of joint pain throughout the body. The oral temperature is 102.4°F and the pulse oximeter reading is 91%. Which action should the emergency department nurse implement first?
- A. Request arterial blood gases STAT.
- B. Administer oxygen via nasal cannula.
- C. Start an IV with an 18-gauge angiocath.
- D. Prepare to administer analgesics as ordered.
Correct Answer: B
Rationale: SpO2 91% and fever suggest hypoxia in SCA crisis; oxygen via cannula (B) addresses this first. ABGs (A), IV (C), and analgesics (D) follow to confirm hypoxia, hydrate, and manage pain.
The nurse identified clotting as a concept related to sickle cell disease. Which intervention should the nurse implement?
- A. Assess for cerebrovascular symptoms.
- B. Keep the head of the bed elevated.
- C. Order a 2,000-mg sodium diet.
- D. Apply antiembolism stockings.
Correct Answer: A
Rationale: SCD causes vaso-occlusion; assessing cerebrovascular symptoms (A) detects stroke risk. HOB elevation (B) is for ICP, sodium diet (C) is for hypertension, and stockings (D) are for DVT.
A 19-year-old college student reports to the health service with a sore throat, malaise, and fever of four days in duration. Examination shows cervical lymphadenopathy and splenomegaly. Temperature is 103°F. Blood is positive for heterophil antibody agglutination test. Which condition does the nurse expect this student to have?
- A. Streptococcal sore throat
- B. Infectious mononucleosis
- C. Rubella
- D. Influenza
Correct Answer: B
Rationale: The symptoms and positive heterophil antibody test are diagnostic for infectious mononucleosis.
The client admitted with full-thickness burns may be developing DIC. Which signs/symptoms would support the diagnosis of DIC?
- A. Oozing blood from the IV catheter site.
- B. Sudden onset of chest pain and frothy sputum.
- C. Foul-smelling, concentrated urine.
- D. A reddened, inflamed central line catheter site.
Correct Answer: A
Rationale: DIC causes uncontrolled bleeding; oozing from IV sites (A) is a hallmark. Chest pain/sputum (B) suggests PE, urine odor (C) is unrelated, and redness (D) indicates infection.