Nokea
An 8-year-old boy is admitted to the unit with a diagnosis of acute lymphocytic leukemia. During a routine physical exam, numerous ecchymotic areas were noted on his body. The parent reported that the child has been more tired than usual personally more tired than usual lately. The parent says that the child has had a cold for the last several weeks and asks if this is related to the leukemia. The nurse's response is based on the knowledge that:
- A. leukemia causes a decrease in the number of normal white blood cells in the body.
- B. a chronic infection such as the child has had makes a child more likely to develop leukemia.
- C. the virus responsible for colds is thought to cause leukemia.
- D. having an infection prior to the onset of leukemia is merely a coincidence.
Correct Answer: A
Rationale: Leukemia reduces normal white blood cells, impairing infection fighting, which may explain the prolonged cold. Infections do not cause leukemia.
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A toddler is diagnosed with sickle cell anemia. Her mother is four months pregnant with her second child. The mother asks if there is any chance the new baby will have sickle cell anemia. She says that neither she nor her husband has sickle cell anemia. What is the best response for the nurse to make?
- A. No. Sickle cell anemia is not inherited.'
- B. Yes. The new baby will also have sickle cell anemia.'
- C. There is a 25% chance that each child you have will have the disease.'
- D. Because neither of you has the disease, another child will not have it. You should ask your physician.'
Correct Answer: C
Rationale: Sickle cell anemia is autosomal recessive. If both parents are carriers (trait), there is a 25% chance each child will have the disease.
The 33-year-old client diagnosed with Stage IV Hodgkin’s lymphoma is at the five (5)-year remission mark. Which information should the nurse teach the client?
- A. Instruct the client to continue scheduled screenings for cancer.
- B. Discuss the need for follow-up appointments every five (5) years.
- C. Teach the client that the cancer risk is the same as for the general population.
- D. Have the client talk with the family about funeral arrangements.
Correct Answer: A
Rationale: Post-remission Hodgkin’s requires ongoing cancer screenings (A) due to recurrence/second cancer risk. Follow-ups are more frequent than 5 years (B), risk remains elevated (C), and funeral plans (D) are premature.
The client had basal cell carcinoma (BCC) lesions excised the day before at an outpatient clinic. The client telephones the nurse expressing concerns that the wounds are draining watery, pale pink fluid and that the small dressing is leaking. Which action should the nurse recommend?
- A. Apply ice to the area
- B. Contact the surgeon
- C. Take pain medication
- D. Change the dressings
Correct Answer: D
Rationale: A. Applying ice to the area is not necessary because the client did not mention swelling. B. Since the wounds do not drain purulent material, contacting the physician is not necessary. C. Because the client is not experiencing pain, pain medication is not needed. D. The nurse should recommend changing the dressing because a small amount of serosanguineous drainage is a normal response to surgical removal of a lesion.
At 1000 hours, the nurse is documenting the administration of 275 mL of compatible platelets, unit number XR123. Which information should the nurse document?
- A. One unit blood was administered over 4 hours.
- B. Platelet XR123 double-checked before infusion.
- C. No transfusion reactions noted during infusion.
- D. D5W infused with platelets to prevent clumping.
- E. Completed 275 mL of platelet infusion started at 0830.
Correct Answer: B, C, E,A.
Rationale: This documents an incomplete blood type, and platelets are unlikely to be administered over 4 hours. B. Documentation should include the type of product infused (platelets), product number (compatible platelets were ordered), and that it was double-checked. C. Documentation should include any adverse reactions. D. Only 0.9% NaCl should be used when administering blood or blood products, and usually only to purge the line before and after administration. E. Documentation should include volume infused. Platelets should be infused as fast as the client can tolerate the infusion to diminish clumping.
The unlicensed assistive personnel (UAP) asks the primary nurse, 'How does someone get hemophilia A?' Which statement would be the primary nurse’s best response?
- A. It is an inherited X-linked recessive disorder.'
- B. There is a deficiency of the clotting factor VIII.'
- C. The person is born with hemophilia A.'
- D. The mother carries the gene and gives it to the son.'
Correct Answer: A
Rationale: Hemophilia A is an X-linked recessive disorder (A), the most precise explanation. Factor VIII deficiency (B) is a result, born with it (C) is vague, and mother-to-son (D) is partial.