Nokea
A nurse is monitoring a client who is undergoing anticoagulant therapy with heparin. Which of the following findings should the nurse identify as a possible indication of hemorrhage?
- A. Rapid pulse
- B. Yellowing of the sclera
- C. Elevated blood pressure
- D. Pale-colored stools
Correct Answer: A
Rationale: The correct answer is A: Rapid pulse. Hemorrhage is a potential complication of anticoagulant therapy with heparin due to the increased risk of bleeding. A rapid pulse can indicate hypovolemia from blood loss, a common sign of hemorrhage. Yellowing of the sclera (choice B) is a sign of jaundice, not directly related to hemorrhage. Elevated blood pressure (choice C) is not typically associated with hemorrhage. Pale-colored stools (choice D) can be indicative of liver or gallbladder issues, but not specifically hemorrhage. Overall, a rapid pulse is the most relevant finding to indicate possible hemorrhage in a client on heparin therapy.
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After seven days of treatment with sulfonamides, a patient's hemoglobin had decreased from 14.7 gm/100ml to 10gm/100ml. The most likely cause of hemolysis in this patient is
- A. Sickle cell disease
- B. Thalassemia minor
- C. Hereditary spherocytosis
- D. Glucose 6-phosphate dehydrogenase deficiency (G6PD)
Correct Answer: D
Rationale: The correct answer is D: Glucose 6-phosphate dehydrogenase deficiency (G6PD). Sulfonamides can trigger hemolysis in patients with G6PD deficiency due to oxidative stress on red blood cells. G6PD enzyme deficiency impairs the ability of red blood cells to combat oxidative damage, leading to hemolysis. In this case, the patient's hemoglobin decreased significantly after sulfonamide treatment, indicating red blood cell destruction. The other choices (A: Sickle cell disease, B: Thalassemia minor, C: Hereditary spherocytosis) are not directly associated with sulfonamide-induced hemolysis and would not explain the observed decrease in hemoglobin levels after treatment.
A patient with leukemia has developed stomatitis and is experiencing a nutritional deficit. An oral anesthetic has consequently been prescribed. What health education should the nurse provide to the patient?
- A. Chew with care to avoid inadvertently biting the tongue.
- B. Use the oral anesthetic 1 hour prior to meal time.
- C. Brush teeth before and after eating.
- D. Swallow slowly and deliberately.
Correct Answer: A
Rationale: The correct answer is A: Chew with care to avoid inadvertently biting the tongue. Stomatitis causes mouth sores, making it crucial for the patient to be cautious while chewing to prevent accidental injury to the mouth. This helps in reducing pain and promoting healing.
Choice B is incorrect because using the oral anesthetic 1 hour prior to mealtime may not provide immediate relief during eating. Choice C is incorrect as brushing teeth before and after eating can irritate the mouth sores further. Choice D is incorrect as swallowing slowly and deliberately does not address the issue of preventing accidental biting of the tongue.
An oncology nurse is caring for a patient with multiple myeloma who is experiencing bone destruction. When reviewing the patient's most recent blood tests, the nurse should anticipate what imbalance?
- A. Hypercalcemia
- B. Hyperproteinemia
- C. Elevated serum viscosity
- D. Elevated RBC count
Correct Answer: A
Rationale: The correct answer is A: Hypercalcemia. In multiple myeloma, bone destruction releases calcium into the bloodstream, leading to hypercalcemia. Elevated serum viscosity (C) is not typically associated with multiple myeloma. Hyperproteinemia (B) may be present due to increased production of abnormal proteins, but it does not directly cause bone destruction. Elevated RBC count (D) is not a common finding in multiple myeloma and is not directly related to bone destruction.
Sickle cell an. Is not complicated by:
- A. papillary necrosis
- B. pancreatitis
- C. osteomyelitis
- D. CHF
Correct Answer: B
Rationale: The correct answer is B: pancreatitis. Sickle cell anemia does not typically manifest with pancreatitis. The pathophysiology of sickle cell anemia involves sickle-shaped red blood cells leading to vaso-occlusive crises, resulting in complications such as papillary necrosis, osteomyelitis, and congestive heart failure. Pancreatitis is not a common complication of sickle cell anemia due to the absence of significant involvement of the pancreas in the disease process. Therefore, option B is the correct choice, as it does not align with the typical complications seen in sickle cell anemia.
Which of the following will be present in chronic bacterial infection?
- A. Neutrophilia
- B. Basophilia
- C. Lymphocytosis
- D. Monocytosis
Correct Answer: D
Rationale: The correct answer is D: Monocytosis. In chronic bacterial infections, there is a prolonged immune response leading to an increased production of monocytes to help combat the infection. Neutrophilia (choice A) is more characteristic of acute bacterial infections. Basophilia (choice B) is associated with allergic reactions or certain blood disorders, not typically seen in bacterial infections. Lymphocytosis (choice C) is more common in viral infections or certain immune responses, not specific to chronic bacterial infections.