Nokea
A nurse is caring for a client who the provider suspects might have pernicious anemia. The nurse should expect the provider to prescribe which of the following diagnostic tests?
- A. Schilling test
- B. Complete blood count (CBC)
- C. Vitamin B12 level
- D. Bone marrow biopsy
Correct Answer: A
Rationale: The correct answer is A: Schilling test. Pernicious anemia is caused by vitamin B12 deficiency, often due to poor absorption. The Schilling test is specifically used to diagnose pernicious anemia by evaluating the body's ability to absorb vitamin B12. The test involves giving the patient a small amount of radioactive vitamin B12 to determine how well it is absorbed and utilized by the body. This test helps to differentiate pernicious anemia from other causes of B12 deficiency.
Choice B (Complete blood count) is a general test that may show abnormalities in red blood cells seen in anemia, but it does not specifically diagnose pernicious anemia. Choice C (Vitamin B12 level) alone may not differentiate between pernicious anemia and other causes of B12 deficiency. Choice D (Bone marrow biopsy) is not typically necessary for diagnosing pernicious anemia and is more invasive compared to the Schilling test.
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While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?
- A. Discontinue the existing IV line
- B. Apply warm compresses
- C. Elevate the extremity
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The correct action is to discontinue the existing IV line first. This is crucial because the client is exhibiting signs of infiltration, which can lead to tissue damage and complications. By removing the IV line, further damage can be prevented. Applying warm compresses or elevating the extremity may not address the underlying issue and could potentially worsen the condition. Notifying the healthcare provider is important but should not be the first step in this situation.
A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?
- A. Electrocardiogram
- B. Chest X-ray
- C. Echocardiogram
- D. MRI of the chest
Correct Answer: D
Rationale: The correct answer is D. MRI of the chest should be clarified because the magnetic field can interfere with the function of the pacemaker, potentially causing harm to the patient. An electrocardiogram, chest X-ray, and echocardiogram are safe imaging tests that do not interfere with the pacemaker. Therefore, D is the correct answer that should be clarified to ensure patient safety.
A nurse is assessing a client before a packed RBC transfusion. What data is most important to obtain?
- A. Blood pressure
- B. Temperature
- C. Respiratory rate
- D. Oxygen saturation
Correct Answer: B
Rationale: The correct answer is B: Temperature. Before a packed RBC transfusion, it is crucial to assess the client's temperature as hyperthermia can indicate a possible transfusion reaction. Monitoring temperature helps in early detection and intervention. Blood pressure (A) is important but not the most crucial in this context. Respiratory rate (C) and oxygen saturation (D) are relevant but may not indicate an immediate issue with the transfusion. Other choices are not provided.
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
- A. Hemoglobin of 12 g/dL
- B. Platelet count of 350,000/mm3
- C. CD4-T-cell count 180 cells/mm3
- D. White blood cell count of 10,000/mm3
Correct Answer: C
Rationale: The correct answer is C: CD4-T-cell count 180 cells/mm3. In HIV care, monitoring the CD4-T-cell count is crucial as it reflects the immune system's ability to fight infections. A low CD4 count indicates a weakened immune system, increasing the client's susceptibility to opportunistic infections. This value guides treatment decisions, such as initiating antiretroviral therapy. The other options, while important, do not directly reflect the client's immune status in the context of HIV. Hemoglobin and platelet counts are relevant for assessing anemia and clotting function, respectively. White blood cell count is a general indicator of infection or inflammation. Prioritizing CD4-T-cell count ensures appropriate management of HIV and prevention of complications.
A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care?
- A. Fresh flowers and potted plants in the room
- B. Visitors from outside the hospital
- C. Foods high in vitamin C
- D. A humidifier in the room
Correct Answer: A
Rationale: The correct answer is A: Fresh flowers and potted plants in the room. Neutropenic clients are at high risk for infections due to low white blood cell count. Fresh flowers and potted plants can harbor bacteria and fungi, increasing the risk of infection. Restricting these items helps minimize exposure to pathogens. Choices B and D are incorrect as long as visitors are screened for infections and the humidifier is cleaned regularly. Choice C, foods high in vitamin C, is incorrect as these foods can actually help boost the immune system.