Nokea
The client diagnosed with sickle cell anemia is experiencing a vaso-occlusive sickle cell crisis secondary to an infection. Which medical treatment should the nurse anticipate the HCP ordering for the client?
- A. Administer meperidine (Demerol) intravenously.
- B. Admit the client to a private room and keep in reverse isolation.
- C. Infuse D5W 0.33% NS at 150 mL/hr via pump.
- D. Insert a 22-French Foley catheter with a urimeter.
Correct Answer: C
Rationale: Hydration with IV fluids (C) prevents sickling in vaso-occlusive crisis. Meperidine (A) is avoided (risks seizures), isolation (B) is excessive, and Foley (D) is unnecessary.
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Which laboratory result would the nurse expect in the client diagnosed with DIC?
- A. A decreased prothrombin time.
- B. A low fibrinogen level.
- C. An increased platelet count.
- D. An increased white blood cell count.
Correct Answer: B
Rationale: DIC consumes clotting factors, lowering fibrinogen (B). PT is prolonged (A), platelets decrease (C), and WBCs (D) are nonspecific.
The client undergoing intensive chemotherapy for Hodgkin’s lymphoma (HL) is hospitalized with fever and depressed immune system functioning. The nurse is administering filgrastim subcutaneously daily. Which laboratory value should the nurse monitor to determine the medication’s effectiveness?
- A. Hemoglobin
- B. Platelet count
- C. Absolute neutrophil count (ANC)
- D. Reed-Sternberg cells
Correct Answer: C
Rationale: A. Epoetin alfa, not filgrastim, is used to treat anemia that is associated with cancer, and its effectiveness would be reflected in the Hgb values. B. Oprelvekin (Neumega), not filgrastim, enhances the synthesis of platelets. C. The nurse should monitor the ANC. Filgrastim (Neupogen) is usually discontinued when the client’s absolute neutrophil count (ANC) is above 1000 cells/mm3. Filgrastim, a granulocyte colony-stimulating factor (G-CSF) analog, is used to stimulate the proliferation and differentiation of granulocytes and treat neutropenia. D. Reed-Sternberg cells are found in lymph node biopsy cells and are indicative of Hodgkin’s lymphoma; they are not monitored to determine the effectiveness of filgrastim, which is used to treat neutropenia.
Which sign would the nurse expect to assess in the client diagnosed with idiopathic thrombocytopenic purpura (ITP)?
- A. Petechiae on the anterior chest, arms, and neck.
- B. Capillary refill of less than three (3) seconds.
- C. An enlarged spleen.
- D. Pulse oximeter reading of 95%.
Correct Answer: A
Rationale: ITP causes low platelets, leading to petechiae (A). Capillary refill (B) is normal, splenomegaly (C) is not primary, and SpO2 95% (D) is normal.
The nurse knows that infectious mononucleosis is caused by which of the following?
- A. Cytomegalovirus
- B. Beta-hemolytic Streptococcus
- C. Epstein-Barr virus
- D. Herpes simplex virus I
Correct Answer: C
Rationale: Infectious mononucleosis is caused by the Epstein-Barr virus.
Which sign/symptom will the nurse expect to assess in the client diagnosed with a vaso-occlusive sickle cell crisis?
- A. Lordosis.
- B. Epistaxis.
- C. Hematuria.
- D. Petechiae.
Correct Answer: C
Rationale: Vaso-occlusive crisis causes ischemia; hematuria (C) results from renal infarction. Lordosis (A) is spinal, epistaxis (B) is bleeding, and petechiae (D) indicate thrombocytopenia.