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After noting that a patient with leukemia has thrombocytopenia, which action will the nurse plan to take?
- A. Palpate lymph nodes for swelling.
- B. Check temperature for elevation.
- C. Inspect skin for bruising or petechiae.
- D. Examine oral mucosa for ulceration.
Correct Answer: C
Rationale: Inspecting the skin for bruising or petechiae is specific to thrombocytopenia, as petechiae are small, red or purple dots that appear on the skin when platelet count is low, indicating a bleeding tendency.
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Which instruction would the nurse include in the teaching plan for a patient newly diagnosed with microcytic hypochromic anemia?
- A. Take enteric-coated iron with each meal.
- B. Take cobalamin with green, leafy vegetables.
- C. Take the iron with orange juice 1 hour before meals.
- D. Decrease the intake of the antiseizure medications to improve anemia.
Correct Answer: C
Rationale: Taking iron with orange juice 1 hour before meals enhances absorption due to vitamin C, optimal for treating microcytic hypochromic anemia.
Which role is attributed to the base in the acid-base balance?
- A. Does not interact with acids.
- B. Promotes the excretion of acid.
- C. Activates the system of acid-base balance.
- D. Increases the action of the hydrogen ions.
Correct Answer: B
Rationale: Bases, like bicarbonate, promote acid excretion by neutralizing hydrogen ions, aiding in maintaining acid-base balance.
Which goal is a primary objective for a patient who has chronic heart failure (HF)?
- A. Maximizing cardiac output.
- B. Maintaining ideal body weight.
- C. Performing daily aerobic exercises.
- D. Maintaining a steady pulse oximetry reading.
Correct Answer: A
Rationale: Maximizing cardiac output is a primary goal for patients with chronic heart failure (HF) because it helps improve tissue perfusion and oxygen delivery to meet the body's demands. It is a crucial aspect of managing heart failure and preventing further complications.
The nurse provides education to a patient about the symptoms of uncontrolled hypertension. Which symptom would the nurse include? Select all that apply.
- A. Fatigue.
- B. Dizziness.
- C. Palpitations.
- D. Cluster headaches.
Correct Answer: A,B,C
Rationale: Fatigue, dizziness, and palpitations are symptoms of uncontrolled hypertension due to cardiovascular strain and vascular effects; cluster headaches are not directly related.
Which explanation will the nurse give a patient with non-Hodgkin lymphoma about the purpose of a planned lumbar puncture?
- A. To rule out any bone marrow involvement.
- B. To determine the level of cell differentiation.
- C. To establish which lymph cell type is involved.
- D. To find any central nervous system involvement.
Correct Answer: D
Rationale: A lumbar puncture in non-Hodgkin lymphoma is used to detect central nervous system involvement by examining cerebrospinal fluid for lymphoma cells.