Nokea
All of these patients are waiting to be admitted by the emergency department nurse. Which one of the following requires the most rapid assessment and care by the nurse?
- A. The patient with hemochromatosis who has symptoms of abdominal pain
- B. The patient with thrombocytopenia who has blood oozing after having a tooth extracted
- C. The patient with chemotherapy-induced neutropenia who has a temperature of 38.2°C (100.8°F)
- D. The patient with a history of sickle cell anemia who has had nausea and diarrhea for 24 hours
Correct Answer: C
Rationale: A neutropenic patient with a fever is assumed to have an infection and developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.
You may also like to solve these questions
The nurse is caring for a patient with polycythemia vera. Which of the following actions should the nurse implement during treatment?
- A. Place the patient on bed rest.
- B. Administer iron supplements.
- C. Avoid use of aspirin products.
- D. Monitor fluid intake and output.
Correct Answer: D
Rationale: Monitoring hydration status is essential in polycythemia vera to prevent thrombosis due to increased blood viscosity. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis (DVT). Iron is contraindicated in patients with polycythemia vera.
The nurse is admitting a patient with hemolytic anemia and notes jaundice of the sclerae. Which of the following laboratory results should the nurse assess?
- A. Schilling test
- B. Bilirubin level
- C. Stool occult blood test
- D. Gastric analysis testing
Correct Answer: B
Rationale: Jaundice is caused by the elevation of bilirubin level associated with red blood cell (RBC) hemolysis. The other tests would not be helpful in monitoring or treating hemolytic anemia.
The nurse has finished teaching a patient about taking oral ferrous sulphate. Which of the following patient statements indicates that additional instruction is needed?
- A. I will call the doctor if my stools start to turn black.
- B. I will take a stool softener if I feel constipated occasionally.
- C. I should take the iron with orange juice about an hour before eating.
- D. I should increase my fluid and fibre intake while I am taking the iron tablets.
Correct Answer: A
Rationale: It is normal for the stools to appear black when a patient is taking iron and the patient should not call the doctor about this. The other patient statements are correct.
The nurse is caring for a patient with a sickle cell crisis. While caring for the patient during the crisis, which of the following actions is priority?
- A. Limit the patient's intake of oral and IV fluids.
- B. Evaluate the effectiveness of opioid analgesics.
- C. Encourage the patient to ambulate as much as tolerated.
- D. Teach the patient about high-protein, high-calorie foods.
Correct Answer: B
Rationale: Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.
The nurse is caring for a patient with neutropenia who is started on a cephalosporin. Which of the following common adverse effects should the nurse observe for in the patient?
- A. Nephrotoxicity
- B. Rash
- C. Ototoxicity
- D. Fever
- E. Pruritus
Correct Answer: B,D,E
Rationale: Adverse effects common to cephalosporins include rashes, fever, and pruritus. Adverse effects common to aminoglycosides include nephrotoxicity and ototoxicity.