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During a physical assessment, the nurse examines the lymph nodes of a patient. Which assessment finding would be of most concern to the nurse?
- A. A 2-cm nontender supraclavicular node
- B. A 1-cm mobile and nontender axillary node
- C. An inability to palpate any superficial lymph nodes
- D. Firm inguinal nodes in a patient with an infected foot
Correct Answer: A
Rationale: The correct answer is A. A 2-cm nontender supraclavicular node is of most concern because enlarged and nontender nodes in this area are highly suggestive of malignancies such as lymphoma. Choice B is less concerning as a 1-cm mobile and nontender axillary node is usually benign. Choice C, an inability to palpate any superficial lymph nodes, could be due to factors like obesity or edema, but it is not necessarily a cause for immediate concern. Choice D, firm inguinal nodes in a patient with an infected foot, may indicate a local reaction to infection rather than a systemic issue related to malignancy.
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A 44-year-old with sickle cell anemia who says his eyes always look sort of yellow
- A. A 23-year-old with no previous health problems who has a nontender lump in the axilla
- B. A 50-year-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue
- C. A 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement
- D. A 44-year-old with sickle cell anemia who says his eyes always look sort of yellow
Correct Answer: B
Rationale: Choice B is the correct answer because the scenario describes a 50-year-old with early-stage chronic lymphocytic leukemia who presents with chronic fatigue. Chronic lymphocytic leukemia commonly presents with symptoms like fatigue, weight loss, and enlarged lymph nodes. The other choices are less likely as they do not match the clinical presentation described in the scenario. Choice A describes a 23-year-old with a nontender lump in the axilla, which is more suggestive of a benign condition like a lipoma. Choice C describes a 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement, which is unrelated to the symptoms of chronic lymphocytic leukemia. Choice D repeats the scenario, which is not relevant in selecting the appropriate answer.
A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take?
- A. Give the PRN diphenhydramine
- B. Send a urine specimen to the laboratory
- C. Administer PRN acetaminophen (Tylenol)
- D. Draw blood for a new type and crossmatch
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A patient who has immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the healthcare provider before obtaining and administering platelets?
- A. Platelet count is 42,000/µL
- B. Petechiae are present on the chest
- C. Blood pressure (BP) is 94/56 mm Hg
- D. Blood is oozing from the venipuncture site
Correct Answer: A
Rationale: The correct answer is A. Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/µL unless the patient is actively bleeding. In this scenario, the platelet count of 42,000/µL is not significantly low to warrant a platelet transfusion without active bleeding. Consulting with the healthcare provider is essential before giving the transfusion to ensure the appropriateness of the treatment. Choices B, C, and D are not directly related to the need for consulting before a platelet transfusion. Petechiae, low blood pressure, and oozing from the venipuncture site are common findings in patients with ITP and may not necessarily contraindicate a platelet transfusion at this platelet count.
The nurse is caring for a patient who is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching?
- A. Check frequently for swollen lymph nodes.
- B. Watch for excessive bleeding or bruising.
- C. Take iron supplements to prevent anemia.
- D. Wash hands regularly and avoid individuals who are ill.
Correct Answer: D
Rationale: The correct answer is D: 'Wash hands regularly and avoid individuals who are ill.' After a splenectomy, the patient is at an increased risk of infection, particularly from gram-positive bacteria. Proper hand hygiene and avoiding contact with sick individuals are crucial to prevent infections. Choices A, B, and C are incorrect because checking for swollen lymph nodes, watching for excessive bleeding or bruising, and taking iron supplements are not specifically related to the increased infection risk post-splenectomy.
The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect?
- A. Yellow-tinged sclerae
- B. Shiny, smooth tongue
- C. Numbness of the extremities
- D. Gum bleeding and tenderness
Correct Answer: C
Rationale: The correct answer is C: Numbness of the extremities. Numbness of the extremities is a common finding in patients with pernicious anemia, which is caused by cobalamin (vitamin B12) deficiency. This deficiency affects the peripheral nervous system, leading to neurological symptoms like numbness and tingling in the extremities. Choices A, B, and D are incorrect: Yellow-tinged sclerae is more indicative of jaundice or liver dysfunction, a shiny smooth tongue is seen in conditions like glossitis, and gum bleeding and tenderness are associated with periodontal disease or vitamin C deficiency, not pernicious anemia.