Nokea
Following morning shift report, the nurse identifies care needs for four clients. Which client should be the nurse’s priority?
- A. The client with lung cancer who is to receive ondansetron 8 mg IV 30 minutes prior to chemotherapy
- B. The client with an absolute neutrophil count of 98/mm3 who needs to be placed on neutropenic precautions
- C. The client who is stable but has breast cancer and is scheduled for external beam radiation in 15 minutes
- D. The client with stomatitis from radiation for tonsillar cancer who is to receive a gastrostomy tube feeding
Correct Answer: B
Rationale: A. No time is noted for the administration of ondansetron (Zofran) prior to chemotherapy treatment; this client is not the nurse’s priority. B. The client with neutropenia should be the nurse’s priority. If seen first, microorganisms from other clients would be less likely to be transmitted to the client. This client is at risk for infection and severe sepsis because the absolute neutrophil count is less than 1001mm3 (normal = 1500 to 8000/mm3). C. This client is stable; another person can take this client to radiation therapy, and the nurse’s assessment can wait until the client returns. D. The tube feeding can be initiated after the needs of the most critical client are met.
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Which sign/symptom should the nurse expect to assess in the client diagnosed with hemophilia A?
- A. Epistaxis.
- B. Petechiae.
- C. Subcutaneous emphysema.
- D. Intermittent claudication.
Correct Answer: A
Rationale: Hemophilia A causes bleeding; epistaxis (A) is common. Petechiae (B) indicate thrombocytopenia, emphysema (C) is unrelated, and claudication (D) is vascular.
The nurse is caring for the female client recovering from a sickle cell crisis. The client tells the nurse her family is planning a trip this summer to Yellowstone National Park. Which response would be best for the nurse?
- A. That sounds like a wonderful trip to take this summer.'
- B. Have you talked to your doctor about taking the trip?'
- C. You really should not take a trip to areas with high altitudes.'
- D. Why do you want to go to Yellowstone National Park?'
Correct Answer: C
Rationale: High altitudes (e.g., Yellowstone) reduce oxygen, risking SCA crisis (C). Generic praise (A), deferring to HCP (B), or questioning motive (D) are less direct.
Which statement made by the parent of a child newly diagnosed with sickle cell anemia indicates a need for more teaching?
- A. We are going to the mountains for our vacation this year.'
- B. It's a good thing she likes to drink juices.'
- C. If she needs something for pain, I will give her baby acetaminophen.'
- D. I will make sure that she doesn't get chilled when it is cold outside.'
Correct Answer: A
Rationale: High altitudes, like mountains, have lower oxygen levels, which can precipitate a sickle cell crisis, indicating a need for more teaching. Drinking juices, using acetaminophen, and avoiding chills are appropriate.
The young adult, diagnosed with hemophilia A, is receiving a monthly scheduled dose of factor VIII cryoprecipitate. The client begins to cry during administration. Which response by the nurse is most appropriate?
- A. “Why are you crying? You seem afraid when I am administering the drug.”
- B. “Is it painful while I’m giving this IV push? If so, I can give it by infusion.”
- C. “I know this is uncomfortable for you; this only takes a few minutes to give.”
- D. “If you want to talk to me about what you are feeling, I am here to listen.”
Correct Answer: D
Rationale: A. Asking a “why” question challenges the client’s feelings. B. This response seeks information but is not most appropriate. It is unlikely that the initial response from an adult would not be crying if the administration of IV factor VIII cryoprecipitate by IV push were painful. C. This response ignores the client’s feelings and presumes that the nurse knows what initiated the client’s crying. D. The nurse is offering self, which is a therapeutic communication technique.
The HCP has ordered one (1) unit of packed RBCs for the client who is right-handed. Which area would be the best place to insert the intravenous catheter?
- A. A
- B. B
- C. C
- D. D
Correct Answer: C
Rationale: For a right-handed client, the non-dominant (left) arm is preferred for IV access (C) to maintain function. Specific sites (A, B, D) depend on image, but C is typically left forearm/antecubital.