Nokea
A nurse is caring for a client with thrombocytopenia. Which action is the highest priority to reduce the risk of bleeding?
- A. Use an electric razor instead of a straight razor.
- B. Apply pressure to any bleeding sites for at least 5 minutes.
- C. Avoid invasive procedures unless absolutely necessary.
- D. Monitor for signs of internal bleeding.
Correct Answer: C
Rationale: The highest priority action to reduce the risk of bleeding in a client with thrombocytopenia is to avoid invasive procedures unless absolutely necessary. Thrombocytopenia is a condition characterized by a low platelet count, which impairs the blood's ability to clot properly. By avoiding invasive procedures, the nurse minimizes the potential for bleeding episodes that could be challenging to control due to the low platelet count. Using an electric razor instead of a straight razor (Choice A) is a good practice to prevent cuts, but it is not as critical as avoiding invasive procedures in this scenario. Applying pressure to bleeding sites (Choice B) and monitoring for signs of internal bleeding (Choice D) are important interventions but are secondary to the priority of preventing bleeding by avoiding invasive procedures.
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What advice should the oncology nurse give to a client planning a beach vacation after completing radiation treatments for cancer?
- A. Avoid getting salt water on the radiation site.
- B. Do not expose the radiation area to direct sunlight.
- C. Have a wonderful time and enjoy your vacation!
- D. Remember you should not drink alcohol for a year.
Correct Answer: B
Rationale: The correct answer is B because the skin at the radiation site is sensitive to sunlight, and exposure can cause further damage. It is crucial to protect the area from direct sunlight to prevent skin irritation or burns. Choice A is incorrect as salt water typically does not pose a significant risk to the radiation site. Choice C is a positive and encouraging response but does not provide necessary advice for post-radiation care. Choice D, while important in some cases, is not directly related to the client's beach vacation after completing radiation treatments.
An emergency department nurse is triaging a 77-year-old man who presents with uncharacteristic fatigue as well as back and rib pain. The patient denies any recent injuries. The nurse should recognize the need for this patient to be assessed for what health problem?
- A. Hodgkin disease
- B. Non-Hodgkin lymphoma
- C. Multiple myeloma
- D. Acute thrombocythemia
Correct Answer: C
Rationale: The correct answer is multiple myeloma (choice C). Back pain is a common presenting symptom in multiple myeloma, especially in older patients. This malignancy can lead to bone pain due to bone destruction and fractures. Hodgkin disease (choice A) and Non-Hodgkin lymphoma (choice B) typically present with symptoms like painless lymph node enlargement, fever, and weight loss. Acute thrombocythemia (choice D) is characterized by an increase in platelet count but is not typically associated with the symptoms described by the patient.
A nurse provides care on a bone marrow transplant unit and is preparing a female patient for a hematopoietic stem cell transplantation (HSCT) the following day. What information should the nurse emphasize to the patient's family and friends?
- A. Your family should gather at the bedside in case there is a negative outcome.
- B. Ensure she abstains from eating any food 24 hours before the procedure.
- C. Wear a hospital gown when entering the patient's room.
- D. Avoid visiting if you've had a recent infection.
Correct Answer: D
Rationale: The correct answer is D: 'Avoid visiting if you've had a recent infection.' Before a hematopoietic stem cell transplantation, it is essential for visitors to refrain from visiting if they have had a recent illness or vaccination to minimize the risk of infection to the patient. Choice A is incorrect because emphasizing a negative outcome is not beneficial to the patient or their family. Choice B is incorrect as it is not necessary to abstain from food for a hematopoietic stem cell transplantation. Choice C is irrelevant to the situation as wearing a hospital gown is not the key information for family and friends to be aware of.
Nurse Farah is caring for a client following a mastectomy. Which assessment finding indicates that the client is experiencing a complication related to the surgery?
- A. Pain at the incision site
- B. Arm edema on the operative side
- C. Sanguineous drainage in the Jackson-Pratt drain
- D. Complaints of decreased sensation near the operative site
Correct Answer: B
Rationale: Arm edema on the operative side (lymphedema) is a known complication after a mastectomy. This can indicate impaired lymphatic drainage, leading to fluid accumulation in the arm. Pain at the incision site is expected postoperatively and may not necessarily indicate a complication. Sanguineous drainage in the Jackson-Pratt drain is a common finding in the immediate postoperative period. Complaints of decreased sensation near the operative site could be related to nerve damage or surgical manipulation, but it is not a typical complication after a mastectomy.
Which of the following is a correct statement by the nurse to a patient under radiation therapy?
- A. Brachytherapy can be administered by a pregnant nurse
- B. Teletherapy makes the patient radioactive
- C. Brachytherapy is an internal radiation therapy
- D. Teletherapy requires proper disposal of feces since feces is not a source of radiation
Correct Answer: C
Rationale: The correct statement is that Brachytherapy is an internal radiation therapy. Brachytherapy involves placing radioactive sources inside or near the tumor, delivering a high radiation dose to the targeted area while minimizing exposure to surrounding healthy tissues. Choices A and B are incorrect because pregnant nurses should not administer radiation therapy and brachytherapy does not make the patient radioactive. Choice D is incorrect as feces is not a source of radiation in teletherapy, and it does not require special disposal.