Nokea
The charge nurse is making assignments on a medical floor. Which client should be assigned to the most experienced nurse?
- A. The client diagnosed with iron-deficiency anemia who is prescribed iron supplements.
- B. The client diagnosed with pernicious anemia who is receiving vitamin B12 intramuscularly.
- C. The client diagnosed with aplastic anemia who has developed pancytopenia.
- D. The client diagnosed with renal disease who has a deficiency of erythropoietin.
Correct Answer: C
Rationale: Aplastic anemia with pancytopenia (C) is complex, risking bleeding/infection, requiring experienced care. Iron (A), B12 (B), and renal anemia (D) are more stable.
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Which client would be most at risk for developing disseminated intravascular coagulation (DIC)?
- A. A 35-year-old pregnant client with placenta previa.
- B. A 42-year-old client with a pulmonary embolus.
- C. A 60-year-old client receiving hemodialysis three (3) days a week.
- D. A 78-year-old client diagnosed with septicemia.
Correct Answer: D
Rationale: Septicemia (D) is a major DIC trigger due to systemic inflammation/coagulation. Placenta previa (A), PE (B), and dialysis (C) are lower risk.
The nurse is discussing prevention of liver cancer with the client. Which vaccine should the nurse recommend?
- A. Varicella vaccine
- B. Hepatitis A vaccine
- C. Meningococcal vaccine
- D. Hepatitis B vaccine
Correct Answer: D
Rationale: A. The varicella vaccine is a live (attenuated) virus administered to protect against chicken pox. There is no evidence that it has an effect on preventing liver cancer. B. Hepatitis A vaccine is given to protect against hepatitis A virus (HAV). HAV can be spread by stool, blood, or food and water that is infected with HAV. There is no evidence that it has an effect on preventing liver cancer. C. Meningococcal vaccine is a vaccine used to prevent meningitis caused by Neisseria meningitidis. There is no evidence that it has an effect on preventing liver cancer. D. Hepatitis B vaccine dramatically reduces the incidence of hepatitis B virus (HBV) and, in turn, prevents liver cancer. HBV is transmitted through contact with blood or body fluids of an infected person, and it can survive outside the body for at least 7 days.
Which situation might cause the nurse to think that the client has von Willebrand’s (vW) disease?
- A. The client has had unexplained episodes of hematemesis.
- B. The client has microscopic blood in the urine.
- C. The client has prolonged bleeding following surgery.
- D. The client developed abruptio placentae.
Correct Answer: C
Rationale: vWD impairs clotting, causing prolonged bleeding post-surgery (C). Hematemesis (A) and hematuria (B) are less specific, and abruptio placentae (D) is unrelated.
The nurse is administering a transfusion of packed red blood cells to a client. Which interventions should the nurse implement? List in order of performance.
- A. Start the transfusion slowly.
- B. Have the client sign a permit.
- C. Assess the IV site for size and patency.
- D. Check the blood with another nurse at the bedside.
- E. Obtain the blood from the laboratory.
Correct Answer: E,C,B,D,A
Rationale: 1. Obtain blood (E): Retrieve from lab. 2. Assess IV site (C): Ensure 18-gauge patency. 3. Sign permit (B): Obtain consent. 4. Check blood (D): Verify with another nurse. 5. Start slowly (A): Infuse at 10–15 mL/hr initially.
The nurse is caring for the client placed on neutropenic precautions. Which interventions should the nurse implement?
- A. Apply pressure for at least 5 minutes to any site that is bleeding.
- B. Prevent anyone from bringing fresh flowers into the client’s room.
- C. Teach the client to avoid eating unwashed fruit and vegetables.
- D. Perform hand hygiene before touching any of the client’s belongings.
- E. Inform the client that fresh water will be delivered every hour.
- F. Stop visitors from entering the room if observed to be coughing.
Correct Answer: B, C, D, F, A.
Rationale: Pressure should be applied to an area that is bleeding when the client has thrombocytopenia, not neutropenia. B. Fresh flowers harbor microorganisms that can cause an infection. C. Unwashed fruits and vegetables have been found to be colonized with various bacteria, particularly gram-negative enteric organisms, as well as pseudomonas and fungi. Recent research indicates that well-washed fresh fruits and vegetables may be eaten. D. Hand hygiene reduces microbial counts on hands and helps to prevent the transmission of microorganisms to the client’s belongings. E. The client should not consume any liquids that have been standing at room temperature for longer than an hour due to risk of microbial colonization. F. Visitors with a transmittable infection place the client at a high risk for becoming infected due to the client’s depressed immune system.