Nokea
A nurse is caring for a client who is about to begin factor VIII therapy to treat hemophilia A. When administering factor VIII, which of the following actions should the nurse take?
- A. Administer the powdered form orally.
- B. Premedicate with aspirin.
- C. Administer it via rapid IV bolus.
- D. Have emergency equipment ready.
Correct Answer: D
Rationale: The correct answer is D. Having emergency equipment ready is crucial when administering factor VIII therapy for hemophilia A due to the risk of potential allergic reactions or adverse events. The nurse should be prepared to manage any complications promptly. Administering the powdered form orally (A) is incorrect as factor VIII is typically given intravenously. Premedicating with aspirin (B) is contraindicated as aspirin can increase the risk of bleeding in hemophilia patients. Administering it via rapid IV bolus (C) is also unsafe as it can cause adverse reactions and should be infused slowly.
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A nurse is assessing a dark-skinned client for pallor. What nursing assessment is best to assess for pallor in this client?
- A. Assess the conjunctiva of the eye.
- B. Have the patient open the hand widely.
- C. Look at the roof of the patient's mouth.
- D. Palpate for areas of mild swelling.
Correct Answer: A
Rationale: The correct answer is A: Assess the conjunctiva of the eye. The conjunctiva is a thin, transparent layer covering the white part of the eye. Pallor, which is paleness of the skin or mucous membranes, is more easily observed in the conjunctiva of the eye in dark-skinned individuals. This area provides a contrast to the skin tone, making it easier to detect subtle changes in color. Assessing the conjunctiva allows for a more accurate evaluation of pallor in dark-skinned clients compared to other areas like the palm, mouth, or palpation for swelling, which may not provide as clear of an indication of pallor.
RBCs break into fragments, they are referred to as schistocytes. These type of cells are seen in
- A. Sickle cell trait
- B. Thalassemia
- C. Microangiopathic hemolytic anemia
- D. Idiopathic thrombocytopenic purpura
Correct Answer: C
Rationale: The correct answer is C, Microangiopathic hemolytic anemia. Schistocytes are fragmented red blood cells caused by mechanical damage as they pass through narrowed vessels. This occurs in conditions like thrombotic thrombocytopenic purpura and hemolytic uremic syndrome, which are types of microangiopathic hemolytic anemia. Sickle cell trait (A) and Thalassemia (B) are genetic disorders affecting red blood cell structure and production, not causing mechanical fragmentation. Idiopathic thrombocytopenic purpura (D) is a disorder characterized by low platelet count, unrelated to RBC fragmentation.
A client is having a radioisotopic imaging scan. What action by the nurse is most important?
- A. Assess the client for shellfish allergies.
- B. Place the client on radiation precautions.
- C. Sedate the client before the scan.
- D. Teach the client about the procedure.
Correct Answer: D
Rationale: The correct answer is D because educating the client about the procedure is crucial for informed consent, cooperation, and reducing anxiety. This empowers the client to participate actively in their care. Assessing for shellfish allergies (A) is irrelevant unless a specific contrast agent is used. Placing the client on radiation precautions (B) is unnecessary for radioisotopic imaging. Sedating the client (C) may not be indicated and should be avoided if possible. Teaching the client about the procedure (D) addresses the immediate need and supports client safety and understanding.
A patient who is suspected of having acute viral hemorrhagic fever reveals history of tick bite. Which of the following is the most possible causative agent?
- A. Hantavirus
- B. Rift Valley virus
- C. Crimean Congo virus
- D. Marburg virus
Correct Answer: C
Rationale: The correct answer is C: Crimean Congo virus. This is because Crimean Congo virus is a tick-borne virus known to cause acute viral hemorrhagic fever. Tick bite history increases suspicion for this virus. A: Hantavirus is transmitted through rodent feces and urine. B: Rift Valley virus is transmitted through mosquito bites. D: Marburg virus is transmitted through contact with infected animals.
A nurse is administering epoetin intravenously to a client who has renal failure. Which of the following actions should the nurse take?
- A. Shake the vial before using.
- B. Administer via IV bolus over 1 to 3 min.
- C. Dilute the drug first with D5W.
- D. Save the used vial for the next dose.
Correct Answer: B
Rationale: The correct answer is B: Administer via IV bolus over 1 to 3 min. This route and method of administration is appropriate for epoetin to ensure proper absorption and effect. Shaking the vial (A) can denature the drug. Diluting with D5W (C) is not recommended as it may alter the drug's effectiveness. Saving the used vial for the next dose (D) is unsafe and violates infection control practices.