Nokea
The client diagnosed with von Willebrand’s disease calls a clinic after experiencing hemarthrosis. The client states that factor concentrate is infusing. Which intervention should the nurse recommend now?
- A. “Take two 325-mg aspirin tablets every 4 hours for pain.”
- B. “Apply a cold pack to the area for 30 minutes every 1 to 2 hours.”
- C. “Come to the clinic; you need an infusion of fresh frozen plasma.”
- D. “If wearing a splint, remove it to avoid compartment syndrome.”
Correct Answer: B
Rationale: A. Aspirin (Ecotrin) and NSAIDs are contraindicated because they interfere with platelet aggregation. B. Hemarthrosis is bleeding into the joint. The pressure of the ice pack and cold will reduce the bleeding and swelling. The ice pack should be covered with a cloth. C. The client and family are usually taught how to administer factor concentrates at home at the first sign of bleeding. D. The splint should be left on initially to control bleeding. The client should be instructed on how to assess for adequate tissue perfusion.
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Following morning shift report, the nurse identifies care needs for four clients. Which client should be the nurse’s priority?
- A. The client with lung cancer who is to receive ondansetron 8 mg IV 30 minutes prior to chemotherapy
- B. The client with an absolute neutrophil count of 98/mm3 who needs to be placed on neutropenic precautions
- C. The client who is stable but has breast cancer and is scheduled for external beam radiation in 15 minutes
- D. The client with stomatitis from radiation for tonsillar cancer who is to receive a gastrostomy tube feeding
Correct Answer: B
Rationale: A. No time is noted for the administration of ondansetron (Zofran) prior to chemotherapy treatment; this client is not the nurse’s priority. B. The client with neutropenia should be the nurse’s priority. If seen first, microorganisms from other clients would be less likely to be transmitted to the client. This client is at risk for infection and severe sepsis because the absolute neutrophil count is less than 1001mm3 (normal = 1500 to 8000/mm3). C. This client is stable; another person can take this client to radiation therapy, and the nurse’s assessment can wait until the client returns. D. The tube feeding can be initiated after the needs of the most critical client are met.
The nurse assesses that the client who is receiving radiation for cervical cancer continues to have diarrhea. Which nursing advice is most appropriate for this client?
- A. Eat a low-residue diet and take sitz baths twice daily.
- B. Drink fluids low in potassium and take frequent tub baths.
- C. Consume more milk products and take frequent showers.
- D. Drink high-sodium fluids and apply hydrocolloid pads to rectum.
Correct Answer: A
Rationale: A. The client with diarrhea should eat a low-residue diet to decrease roughage and bowel irritability and take sitz (or tub) baths twice daily to increase comfort. B. Intake of fluids that are high in potassium (not low) is recommended to replace electrolytes lost through diarrhea. C. Milk products are discouraged because they increase bowel irritability. D. Intake of fluids high in sodium should be avoided because it contributes to water retention, but hydrocolloid pads may be used on reddened areas to promote healing.
The nurse is administering vesicant chemotherapy medications such as doxorubicin hydrochloride to clients. Which nursing actions should the nurse implement to prevent extravasation?
- A. Give through an IV catheter in a large peripheral vein if infusing in less than 60 minutes.
- B. Check patency every 5 to 10 minutes during infusion and ask about IV site discomfort.
- C. Check the IV pump and alarm for indications of an infiltration of the medication.
- D. Check for blood return in a central venous catheter prior to administration of the vesicant.
- E. Use small-gauged syringes with small barrels when flushing any access devices with saline.
Correct Answer: A, B, D
Rationale: A peripheral IV catheter may be used for a vesicant if administration time is less than 60 minutes, a large vein is used, and there is careful monitoring of the IV site. B. Checking for patency and asking about discomfort at the IV site will help prevent an infiltration. C. IV pumps and alarms cannot be relied upon to detect extravasation because infiltration usually does not cause sufficient pressure to trigger an alarm. D. Checking for blood return in the central venous catheter prior to administration will help ensure that the medication is being administered into a vessel and not into tissues. E. Small-gauge syringes with small barrels produce high pressures and may cause injury to the blood vessel or may damage a central line catheter and should not be used.
The nurse is preparing the client for a bone marrow biopsy of the iliac crest. Place the nurse’s actions in order of priority.
- A. Premedicate with lorazepam
- B. Obtain a signed informed consent
- C. Position prone and provide emotional support
- D. Verify that the HCP has explained the procedure
- E. Check for signs of bleeding every 2 hours for 24 hours
- F. Teach what may be expected during the procedure
Correct Answer: D, F, B, A, C, E:
Rationale: Verify that the HCP has explained the procedure. The HCP should include the purpose, intended outcomes, and potential complications. F. Teach what may be expected during the procedure, including that pressure or discomfort may be experienced. B. Obtain a signed informed consent. This is obtained only after the HCP has met with the client and teaching is completed. A. Premedicate with lorazepam (Ativan). Midazolam (Versed) is another option for sedation. A local anesthetic is used at the site, and some clients may not need sedation. C. Position prone and provide emotional support. The client should be prone because the iliac crest is the site being used for this biopsy, but the position will vary with the site. Holding the client’s hand and using guided imagery help support the client. E. Check for signs of bleeding every 2 hours for 24 hours. A pressure dressing is applied by the HCP after the procedure. Ice can be applied to reduce bruising and for comfort.
The client diagnosed with non-Hodgkin's lymphoma is scheduled for a lymphangiogram. Which information should the nurse teach?
- A. The scan will identify any malignancy in the vascular system.
- B. Radiopaque dye will be injected between the toes.
- C. The test will be done similar to a cardiac angiogram.
- D. The test will be completed in about five (5) minutes.
Correct Answer: B
Rationale: Lymphangiogram involves dye injection between toes (B) to visualize lymphatics. It’s not vascular (A), unlike cardiac angiogram (C), and takes longer than 5 minutes (D).