Nokea
For which of the following problems should the nurse monitor in the patient with multiple myeloma?
- A. Uncontrolled bleeding
- B. Liver engorgement
- C. Respiratory distress
- D. Pathological fractures
Correct Answer: D
Rationale: The correct answer is D: Pathological fractures. In multiple myeloma, abnormal plasma cells can weaken the bones, leading to fractures even with minimal trauma. The nurse should monitor for signs of bone pain, decreased mobility, and pathological fractures to prevent complications.
Uncontrolled bleeding (A) is not typically associated with multiple myeloma. Liver engorgement (B) is more commonly seen in conditions like congestive heart failure or liver disease. Respiratory distress (C) is not a common manifestation of multiple myeloma.
Therefore, the nurse should focus on monitoring for pathological fractures as a priority in a patient with multiple myeloma.
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The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?
- A. “Is there anything that you are stressed about right now that I should know?”
- B. “What reasons do you think are contributing to your fatigue?”
- C. “What are your normal work hours?”
- D. “Are you sleeping 8 hours a night?”
Correct Answer: B
Rationale: The correct answer is B because it encourages the patient to reflect on their own thoughts and identify potential causes of their fatigue. It allows the patient to express their own insights and helps the nurse understand the underlying reasons for the fatigue. Choice A focuses on stress, which may not be the main cause of fatigue. Choice C is irrelevant to exploring the fatigue further. Choice D assumes that lack of sleep is the main issue, which may not be the case for the patient.
Then the drug is stopped. When should treatment resume?
- A. When the WBC falls to 5,000mm3
- B. When lost hair begins to grow back
- C. When the WBC count rises to 50,000/mm3
- D. When the client displays anemia
Correct Answer: A
Rationale: The correct answer is A: When the WBC falls to 5,000mm3. This is because a low WBC count indicates potential bone marrow suppression from the drug. Resuming treatment at this point ensures the bone marrow has recovered enough to handle the drug's effects.
Summary:
- Choice B: Hair regrowth is not a reliable indicator of bone marrow recovery.
- Choice C: A high WBC count suggests potential toxicity, not readiness for treatment.
- Choice D: Anemia is a late sign of bone marrow suppression, not an appropriate indicator to resume treatment.
A guest who is diabetic attended a bridal affair. The guest started to tremble and started to feel dizzy. Luckily a nurse is present. The best action for the nurse to take is to:
- A. encourages the guest to eat some
- B. call the guest’s personal hygiene
- C. offer the guest a peppermint
- D. give the guest a glass of orange juice
Correct Answer: D
Rationale: The correct answer is D: give the guest a glass of orange juice. This is the best action because the guest is likely experiencing hypoglycemia due to being diabetic. Orange juice contains fast-acting sugar that can quickly raise blood sugar levels. Encouraging the guest to eat some (choice A) may take longer to have an effect. Calling the guest's personal hygiene (choice B) is irrelevant to the situation. Offering the guest a peppermint (choice C) will not effectively raise blood sugar levels.
The nurse observes the temperature record of a client and relates the fever to the brain infection the client currently has. The nurse knows that a high temperature may lead to an increased cerebral irritation. Which of the ff measures can help the nurse control the clients body temperature? Choose all that apply
- A. Providing tepid sponge bath
- B. Applying ice packs
- C. Administering prescribed antipyretics
- D. Keeping the room temperature warm
Correct Answer: A
Rationale: The correct answer is A: Providing tepid sponge bath. This measure helps lower body temperature through evaporation of water from the skin. It is effective in managing fever without causing shivering or discomfort. Ice packs (B) can lead to vasoconstriction and shivering, raising body temperature. Antipyretics (C) are drugs that can reduce fever but may not address the underlying cause. Keeping the room warm (D) can exacerbate fever by hindering heat dissipation.
Maintaining the infusion rate of hyperalimentation solutions is a nursing responsibility. What side effects would you anticipate from too rapid infusion rate?
- A. Cellular dehydration and potassium
- B. Hypoglycemia and hypovolemia
- C. Potassium excess and CHF
- D. Circulatory overload and hypoglycemia SITUATION: In the recall of the fluids and electrolytes, the nurse should be able to understand the calculations and other conditions related to loss or retention.
Correct Answer: D
Rationale: Rationale:
1. Rapid infusion of hyperalimentation solutions can lead to circulatory overload due to increased fluid volume in the circulatory system.
2. Circulatory overload can result in symptoms such as hypertension, tachycardia, and edema.
3. Hypoglycemia can occur as a result of excess insulin release due to the sudden increase in glucose from the hyperalimentation solution.
Summary:
A. Cellular dehydration and potassium: Incorrect. Rapid infusion would lead to fluid overload, not dehydration.
B. Hypoglycemia and hypovolemia: Incorrect. Hypovolemia is unlikely with rapid infusion, and hypoglycemia is a possible side effect.
C. Potassium excess and CHF: Incorrect. Rapid infusion may cause circulatory overload, not CHF, and potassium excess is not a common side effect.
D. Circulatory overload and hypoglycemia: Correct. These are the most likely side effects of rapid