Nokea
The 24-year-old female client is diagnosed with idiopathic thrombocytopenic purpura (ITP). Which question would be important for the nurse to ask during the admission interview?
- A. Do you become short of breath during activity?'
- B. How heavy are your menstrual periods?'
- C. Do you have a history of deep vein thrombosis?'
- D. How often do you have migraine headaches?'
Correct Answer: B
Rationale: ITP causes bleeding; heavy menstrual periods (B) assess bleeding severity. Dyspnea (A), DVT (C), and migraines (D) are unrelated.
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The nurse is assessing an African American client diagnosed with sickle cell crisis. Which assessment datum is most pertinent when assessing for cyanosis in clients with dark skin?
- A. Assess the client’s oral mucosa.
- B. Assess the client’s metatarsals.
- C. Assess the client’s capillary refill time.
- D. Assess the sclera of the client’s eyes.
Correct Answer: A
Rationale: Oral mucosa (A) is the best site to assess cyanosis in dark skin, showing dusky color. Metatarsals (B) and sclera (D) are less reliable, and capillary refill (C) assesses perfusion.
The nurse completed teaching the client who had a bone marrow transplant (BMT). Which statement by the client indicates the client misunderstood the expected changes following a BMT?
- A. “I may gain weight from my immunosuppressant medication.”
- B. “Sterility can occur from the chemotherapy and radiation.”
- C. “I may have vision changes from the total body irradiation.”
- D. “Changes to my mouth could include a white, patchy tongue.”
Correct Answer: D
Rationale: A. A common side effect of immunosuppressant medications is weight gain. B. Sterility can occur as a result of chemotherapy and the total body irradiation after BMT. C. Changes in vision are common as a result of the total body irradiation after BMT. D. A white, patchy tongue is a sign of a fungal infection with Candidiasis albicans and would not be an expected change.
A client who has been diagnosed as having pernicious anemia asks how long she will have to take shots. What is the best answer for the nurse to give?
- A. Until your blood count returns to normal.'
- B. Until you are feeling better.'
- C. For the rest of your life.'
- D. That varies with each person. Ask your doctor.'
Correct Answer: C
Rationale: Due to the absence of intrinsic factor, pernicious anemia requires lifelong vitamin B12 injections.
The nurse is caring for clients on a medical floor. After the shift report, which client should be assessed first?
- A. The client who is two-thirds of the way through a blood transfusion and has no complaints of dyspnea or hives.
- B. The client diagnosed with leukemia who has a hematocrit of 18% and petechiae covering the body.
- C. The client with peptic ulcer disease who called over the intercom to say that he is vomiting blood.
- D. The client diagnosed with Crohn’s disease who is complaining of perineal discomfort.
Correct Answer: C
Rationale: Vomiting blood (C) indicates active GI bleeding, a life-threatening emergency. Low Hct/petechiae (B) is urgent but stable, transfusion (A) is uneventful, and perineal discomfort (D) is least urgent.
Fifteen minutes after the nurse has initiated a transfusion of packed red blood cells, the client becomes restless and complains of itching on the trunk and arms. Which intervention should the nurse implement first?
- A. Collect urine for analysis.
- B. Notify the laboratory of the reaction.
- C. Administer diphenhydramine, an antihistamine.
- D. Stop the transfusion at the hub.
Correct Answer: D
Rationale: Restlessness/itching suggest a transfusion reaction; stopping at the hub (D) prevents further reaction. Urine collection (A), notification (B), and Benadryl (C) follow.