Nokea
The 33-year-old client diagnosed with Stage IV Hodgkin’s lymphoma is at the five (5)-year remission mark. Which information should the nurse teach the client?
- A. Instruct the client to continue scheduled screenings for cancer.
- B. Discuss the need for follow-up appointments every five (5) years.
- C. Teach the client that the cancer risk is the same as for the general population.
- D. Have the client talk with the family about funeral arrangements.
Correct Answer: A
Rationale: Post-remission Hodgkin’s requires ongoing cancer screenings (A) due to recurrence/second cancer risk. Follow-ups are more frequent than 5 years (B), risk remains elevated (C), and funeral plans (D) are premature.
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The nurse has identified the concept of cellular deviation for a client diagnosed with chronic myelogenous leukemia. Which intervention should the nurse implement? Select all that apply.
- A. Screen visitors for infection before allowing them to enter the room.
- B. Assess the client’s vital signs every four (4) hours.
- C. Do not allow fresh fruits and vegetables on diet trays.
- D. Monitor the client’s white blood cell count.
- E. Place the client on droplet isolation.
- F. Check the client’s bone marrow results daily.
Correct Answer: A,C,D
Rationale: Screening visitors (A), avoiding fresh produce (C), and monitoring WBCs (D) reduce infection risk in CML. Vitals (B) are routine, droplet isolation (E) is excessive, and daily bone marrow (F) is impractical.
The client had basal cell carcinoma (BCC) lesions excised the day before at an outpatient clinic. The client telephones the nurse expressing concerns that the wounds are draining watery, pale pink fluid and that the small dressing is leaking. Which action should the nurse recommend?
- A. Apply ice to the area
- B. Contact the surgeon
- C. Take pain medication
- D. Change the dressings
Correct Answer: D
Rationale: A. Applying ice to the area is not necessary because the client did not mention swelling. B. Since the wounds do not drain purulent material, contacting the physician is not necessary. C. Because the client is not experiencing pain, pain medication is not needed. D. The nurse should recommend changing the dressing because a small amount of serosanguineous drainage is a normal response to surgical removal of a lesion.
The nurse writes the problem of 'grieving' for a client diagnosed with non-Hodgkin's lymphoma. Which collaborative intervention should be included in the plan of care?
- A. Encourage the client to talk about feelings of loss.
- B. Arrange for the family to plan a memorable outing.
- C. Refer the client to the American Cancer Society’s Dialogue group.
- D. Have the chaplain visit with the client.
Correct Answer: C
Rationale: Grieving requires collaborative support; ACS Dialogue group (C) provides peer support. Talking (A) is independent, outings (B) are nonspecific, and chaplain visits (D) are spiritual, not primary.
A toddler is diagnosed with sickle cell anemia. Her mother is four months pregnant with her second child. The mother asks if there is any chance the new baby will have sickle cell anemia. She says that neither she nor her husband has sickle cell anemia. What is the best response for the nurse to make?
- A. No. Sickle cell anemia is not inherited.'
- B. Yes. The new baby will also have sickle cell anemia.'
- C. There is a 25% chance that each child you have will have the disease.'
- D. Because neither of you has the disease, another child will not have it. You should ask your physician.'
Correct Answer: C
Rationale: Sickle cell anemia is autosomal recessive. If both parents are carriers (trait), there is a 25% chance each child will have the disease.
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.