Nokea
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.
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The nurse is caring for the client following a total laryngectomy for treatment of laryngeal cancer. The nurse should plan consultations with which members of the multidisciplinary team?
- A. Physical therapist
- B. Dietitian
- C. Speech therapist
- D. Dentist
- E. Occupational therapist
- F. Social worker
Correct Answer: A, B, C, F
Rationale: Total laryngectomy is removal of the entire larynx as well as the hyoid bone, the true vocal cords, the false vocal cords, the epiglottis, the cricoid cartilage, and two to three tracheal rings. The physical therapist is needed for neck exercises. B. The dietitian is needed to ensure adequacy of oral intake. C. The speech therapist is needed for other forms of communication and swallowing. D. The dentist is not routinely consulted when caring for a laryngectomy client. E. An occupational therapist is not routinely consulted when caring for a laryngectomy client. F. The social worker is needed for contact with outside resources to assist the client in ongoing needs.
The client is diagnosed with hemophilia. Which safety precaution should the nurse encourage?
- A. Wear helmets and pads during contact sports.
- B. Take antibiotics prior to any dental work.
- C. Keep clotting factor VIII on hand at all times.
- D. Use ibuprofen, an NSAID, for mild pain.
Correct Answer: C
Rationale: Hemophilia requires factor VIII availability (C) for bleeding emergencies. Contact sports (A) are risky, antibiotics (B) are for endocarditis, and ibuprofen (D) increases bleeding.
A child is being evaluated for possible leukemia. Which assessment finding is most likely to be present?
- A. Numerous bruises on the child's body
- B. Ruddy complexion
- C. Diarrhea and vomiting
- D. Chest pain
Correct Answer: A
Rationale: Numerous bruises are common in leukemia due to decreased platelets from bone marrow failure.
The client hospitalized with cervical cancer is receiving radiation therapy via a temporary radioactive cervical implant. Which nursing actions would be appropriate for this client?
- A. Minimize anxiety and confusion by telling the client the reason for the time and distance limitations.
- B. Utilize the unit’s common film badge that indicates the cumulative radiation exposure while caring for the client.
- C. Organize cares to limit the amount of time spent in direct contact with the client receiving internal radiation.
- D. Use shielding if delivering care within close proximity to the client, such as checking placement of the implant.
- E. Encourage frequent oral care with warm saline rinses to help with irritation of oral mucosa.
Correct Answer: A, C, D
Rationale: A. Safety measures for caring for someone undergoing internal radiation therapy include limiting time, distance, and shielding. It would be important to make the client aware of the time and distance limitations to help ease anxiety. B. A personal, not shared, film badge should be worn so cumulative radiation exposure can be measured accurately. C. Organizing care would be appropriate in order to limit the exposure to radiation. D. Shielding is important for keeping caregivers safe from potential radiation exposure. E. The implant is placed in the vaginal canal and has no impact on oral mucosa.
The client with Hodgkin’s lymphoma receives radiation treatments. The nurse should monitor the client for which specific symptoms of radiation pneumonitis?
- A. Tachypnea, hypotension, and fever
- B. Cough, elevated temperature, and dyspnea
- C. Bradypnea, cough, and decreased urine output
- D. Cough, tachycardia, and altered mental status
Correct Answer: B
Rationale: A. Hypotension is a symptom that is not common in radiation pneumonitis. B. Cough, fever, and dyspnea are classic symptoms in radiation pneumonitis due to a decrease in the surfactant in the lung. C. Decreased urine output is a symptom that is not common in radiation pneumonitis. D. Altered mental status is a symptom that is not common in radiation pneumonitis.