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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.
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The nurse working in the bloodmobile is screening clients to determine if they qualify for blood donation of whole blood. Besides asking for identification and age, which questions should the nurse ask during the screening interview?
- A. “If you have a tattoo, on what date did you receive the tattoo?”
- B. “Have you had any close contact with anyone with HIV or hepatitis?”
- C. “If you smoke, when was the last time you smoked tobacco products?”
- D. “When were you last immunized for rubella, mumps, or varicella?”
- E. “Did you receive blood products anywhere outside of the United States?”
Correct Answer: A, B, D, E
Rationale: Persons ineligible to donate blood include those with a history of a recent tattoo. B. Persons ineligible to donate blood include those who’ve had close contact with a person with HIV or hepatitis. C. Persons who smoke tobacco products may donate blood unless they have a recent history of asthma. D. Persons ineligible to donate blood include those immunized for rubella, mumps, or varicella within the last month. E. Persons ineligible to donate blood include those receiving transfusions in the United Kingdom, Gibraltar, or the Falkland Islands because of the increased likelihood of transmitting Creutzfeldt-Jakob disease.
A coworker being oriented by another nurse states, “I’m confused; a physician told me that graft-versus-host disease (GVHD) symptoms were desirable for a particular client after a bone marrow transplant.” Which should be the nurse’s best response?
- A. “GVHD isn’t desirable. Maybe you heard the physician wrong.”
- B. “That’s interesting. Did the client have a gastrointestinal tumor?”
- C. “That’s right if the transplant involved using autologous stem cells.”
- D. “GVHD is sometimes desirable with a hematological malignancy.”
Correct Answer: D
Rationale: A. GVHD is desirable if the primary source is hematological. B. Bone marrow transplant is not a treatment for GI malignancies unless the primary source is hematological. C. GVHD does not occur when a person receives autologous (his or her own) cells during a transplant. D. GVHD is sometimes desirable with a hematological malignancy. The donor lymphocytes can mount a reaction against any lingering tumor cells and destroy them.
The nurse writes a diagnosis of altered tissue perfusion for a client diagnosed with anemia. Which interventions should be included in the plan of care? Select all that apply.
- A. Monitor the client’s hemoglobin and hematocrit.
- B. Move the client to a room near the nurse’s desk.
- C. Limit the client’s dietary intake of green vegetables.
- D. Assess the client for numbness and tingling.
- E. Allow for rest periods during the day for the client.
Correct Answer: A,D,E
Rationale: Monitoring Hb/Hct (A), assessing numbness/tingling (D), and rest periods (E) address perfusion in anemia. Proximity to desk (B) is nonspecific, and limiting greens (C) is for anticoagulation, not anemia.
The nurse is working in a blood bank facility procuring units of blood from donors. Which client would not be a candidate to donate blood?
- A. The client who had wisdom teeth removed a week ago.
- B. The nursing student who received a measles immunization two (2) months ago.
- C. The mother with a six (6)-week-old newborn.
- D. The client who developed an allergy to aspirin in childhood.
Correct Answer: C
Rationale: Recent childbirth (C) (within 6 months) disqualifies blood donation due to anemia risk. Wisdom teeth (A), immunization (B), and aspirin allergy (D) are not contraindications.
The nurse writes a nursing problem of 'altered nutrition' for a client diagnosed with leukemia who has received a treatment regimen of chemotherapy and radiation. Which nursing intervention should be implemented?
- A. Administer an antidiarrheal medication prior to meals.
- B. Monitor the client's serum albumin levels.
- C. Assess for signs and symptoms of infection.
- D. Provide skin care to irradiated areas.
Correct Answer: B
Rationale: Altered nutrition requires monitoring serum albumin (B) to assess protein status. Antidiarrheals (A) are symptom-specific, infection (C) is unrelated, and skin care (D) addresses radiation effects.