Nokea
A nurse is reinforcing teaching with a client who is to undergo a bone marrow aspiration. Which of the following statements should the nurse include in the teaching?
- A. You will have the bone marrow taken from your femur.
- B. I will hold pressure to the site after the procedure.
- C. You will not receive a local anesthetic agent for this procedure.
- D. You will need to fast for 2 hours before the procedure.
- E. The procedure will take 4 hours.
- F. You should avoid moving for 24 hours after.
- G. You'll feel intense pain throughout.
Correct Answer: B
Rationale: Pressure is applied post-procedure to prevent bleeding; marrow is typically taken from the iliac crest, local anesthetic is used, and fasting isn't required.
You may also like to solve these questions
A nurse is collecting data from a client who is perimenopausal. Which of the following findings is the priority for the nurse to report to the provider?
- A. Difficulty sleeping
- B. Hot flashes
- C. Vaginal dryness
- D. Urinary frequency
Correct Answer: D
Rationale: Perimenopause involves hormonal shifts causing various symptoms, but priority follows clinical urgency. Urinary frequency stands out it could indicate a urinary tract infection, bladder dysfunction, or even a gynecologic issue like prolapse, all requiring prompt evaluation. Difficulty sleeping, hot flashes, and vaginal dryness are classic perimenopausal symptoms from estrogen decline, managed symptomatically unless severe. Frequency, however, suggests a potential complication beyond hormonal changes, possibly impacting renal or pelvic health. Using the ABCs or Maslow's hierarchy, urinary issues tie to elimination needs, outranking sleep or comfort concerns. Reporting this ensures timely diagnosis (e.g., urinalysis) and treatment, preventing progression to pyelonephritis or chronic conditions, making it the most pressing finding to escalate.
A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?
- A. Leave the television on in the client's room
- B. Raise all four side rails while the client is in bed.
- C. Move the overbed table away from the bed.
- D. Apply a motion sensor mat to the client's bed
Correct Answer: D
Rationale: A motion sensor mat alerts staff to movement, reducing fall risk in dementia clients. TV can agitate, four rails are a restraint, and moving the table doesn't directly prevent falls.
A nurse is reinforcing teaching with a client who is starting to take metformin extended release. Which of the following instructions should the nurse include in the instructions?
- A. Monitor blood glucose while taking this medication
- B. Expect muscle pain while taking this medication.
- C. Take the medication with breakfast.
- D. Chew the medication before swallowing.
- E. Take it on an empty stomach.
- F. Expect weight gain as a side effect.
- G. Avoid all carbohydrates while on this.
Correct Answer: A
Rationale: Metformin requires glucose monitoring to assess efficacy and prevent hypoglycemia; muscle pain isn't typical, it's taken with food to reduce GI upset, and it's not chewed.
NURSES’ NOTES
1000:
Client reports that over the past 2 months they have noticed multiple changes with their body. They have a decrease in activity tolerance, feel tired all the time, and have had difficulty remembering things. The client also states they bruise easily, are experiencing constipation, and they no longer tolerate the cold like they used to.
Client states they are concerned about exposure to seasonal viruses from other patrons.
Reports that they are currently experiencing a headache with a pain of 3 on a scale of 0 to 10.
Actions to Take
• Limit caffeine intake.
• Observe the need to administer sumatriptan.
• Withhold lithium.
Potential Condition
• Influenza
• Lithium toxicity
• Migraine
Parameters to Monitor
• Flashing lights
• Blurred vision
• Chest pain
A nurse in a provider's office is caring for a client who reports changes in their health over the past 2 months. What condition is the client most likely experiencing?
- A. Influenza
- B. Lithium toxicity
- C. Migraine
- D. Hypothyroidism
Correct Answer: D, A
Rationale: Symptoms like decreased activity tolerance, fatigue, memory issues, bruising, constipation, and cold intolerance over 2 months suggest hypothyroidism thyroid hormone deficiency slows metabolism, causing systemic effects. Influenza is acute, with fever and respiratory symptoms, not chronic fatigue or bruising. Lithium toxicity includes tremor or confusion, but not cold intolerance or constipation as primary signs. Migraine causes headaches (here, 3/10), but not multisystem changes like bruising or memory loss. Hypothyroidism fits the gradual onset and constellation fatigue from low energy, memory fog from cerebral hypoperfusion, and constipation from sluggish gut motility requiring thyroid function tests (e.g., TSH), making it the most likely condition.
Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Exhibit 5
Diagnostic Results
1000:
Hct 24% (37% to 47%)
Hgb 8 g/dL (12 to 16 g/dL)
RBC count 3 x 10⁶ µL (4.2 to 5.4 x 10⁶ µL)
Ferritin 8 ng/mL (10 to 150 ng/mL)
WBC count 9,000/mm³ (5,000 to 10,000/mm³)
Platelet count 180,000/mm³ (150,000 to 400,000/mm³)
Vitamin B₁₂ 159 pg/mL (160 to 950 pg/mL)
1030:
Stool for fecal occult blood negative
A nurse is assisting in the care of the client who has iron deficiency anemia. Which of the following instructions should the nurse include?
- A. Take an antacid within 30 min after medication administration.
- B. Increase sources of fiber in the diet.
- C. Take the medication with a source of vitamin C.
- D. Increase intake of milk and dairy products.
- E. Take the medication on an empty stomach.
Correct Answer: C
Rationale: Iron deficiency anemia treatment hinges on maximizing iron absorption. Taking the medication with vitamin C enhances uptake ascorbic acid converts ferric to ferrous iron, boosting bioavailability in the acidic stomach environment, a cornerstone of anemia management. Antacids raise gastric pH, binding iron and reducing absorption, counterproductive to correcting deficiency. Increasing fiber mitigates constipation, a side effect of iron, but isn't the primary administration focus. Milk and dairy, high in calcium, inhibit iron absorption by competing for uptake sites, worsening anemia if paired with supplements. Vitamin C's synergistic effect backed by dietary guidelines optimizes therapy, especially critical with low ferritin (8 ng/mL, Exhibit 1), empowering the client to improve hemoglobin efficiently while minimizing common pitfalls, making it the essential instruction.