Nokea
A nurse is preparing to administer a blood transfusion to an older adult. Understanding age-related changes, what alterations to the usual protocol are necessary for the nurse to implement? (Select all that apply.)
- A. Monitor vital signs every 15 minutes
- B. Hold other IV fluids running
- C. Premedicate to prevent reactions
- D. Transfuse each unit over 8 hours
Correct Answer: A,B
Rationale: Older adults require frequent vital sign monitoring (every 15 minutes) due to subtle signs of transfusion reactions and holding other IV fluids to prevent fluid overload. Premedication and prolonged transfusion times are not standard alterations.
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The nurse assesses a client's oral cavity and makes the discovery shown in the photo below: What action by the nurse is most appropriate?
- A. Encourage the client to have genetic testing
- B. Instruct the client on high-fiber foods
- C. Place the client in neutropenic precautions
- D. Teach the client about cobalamin therapy
Correct Answer: D
Rationale: The condition shown is glossitis, characteristic of B12 deficiency anemia, treated with cobalamin (vitamin B12). Genetic testing, high-fiber foods, or neutropenic precautions are not relevant to this condition.
The nurse is caring for a client with leukemia who has the priority problem of fatigue. What action by the client indicates this need has been met?
- A. Doing activities of daily living (ADLs) using rest periods
- B. Helping plan a daily activity schedule
- C. Requesting a sleeping pill at night
- D. Telling visitors to leave when fatigued
Correct Answer: A
Rationale: Fatigue is a common problem for clients with leukemia. This client is managing his or her own ADLs using rest periods, which indicates an understanding of fatigue and how to control it. Helping to plan an activity schedule is a lesser indicator. Requesting a sleeping pill does not control fatigue during the day. Asking visitors to leave when tired is another lesser indicator. Managing ADLs using rest periods demonstrates the most comprehensive management strategy.
A nurse is caring for a young male client with lymphoma who is to begin treatment. What teaching topic is a priority?
- A. Genetic testing
- B. Sperm banking
- C. Treatment options
- D. Lifestyle changes
Correct Answer: B
Rationale: All teaching topics are important to the client with lymphoma, but for a young male, sperm banking is of appropriate concern if the client is going to have radiation to the lower abdomen or pelvis.
The nurse instructor is best?
- A. Because of immunosuppression, the donor cells take over.
- B. In like a transfusion reaction because no perfect matches exist.
- C. The client's cells are fighting donor cells for dominance.
- D. The donor's cells are actually attacking the client's cells.
Correct Answer: D
Rationale: Graft versus host disease is an autoimmune-type process in which the donor cells recognize the client's cells as foreign and begin attacking them. The other answers are not accurate.
A student studying leukemia learns the risk factors for developing this disorder. Which risk factors does this include? (Select all that apply.)
- A. Chemical exposure
- B. Genetically modified foods
- C. Ionizing radiation exposure
- D. Vaccinations
- E. Viral infections
Correct Answer: A,C,E
Rationale: Chemical exposure, ionizing radiation, and viral infections are known risk factors for leukemia. Genetically modified foods and vaccinations have not been established as risk factors.