Nokea
The client is admitted to the emergency department after a motor-vehicle accident. The nurse notes profuse bleeding from a right-sided abdominal injury. Which intervention should the nurse implement first?
- A. Type and crossmatch for red blood cells immediately (STAT).
- B. Initiate an IV with an 18-gauge needle and hang normal saline.
- C. Have the client sign a consent for an exploratory laparotomy.
- D. Notify the significant other of the client’s admission.
Correct Answer: B
Rationale: Profuse bleeding requires immediate IV access with 18-gauge and NS (B) to stabilize hemodynamics. Crossmatch (A), consent (C), and notification (D) follow.
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Which client should be assigned to the experienced medical-surgical nurse who is in the first week of orientation to the oncology floor?
- A. The client diagnosed with non-Hodgkin’s lymphoma who is having daily radiation treatments.
- B. The client diagnosed with Hodgkin’s disease who is receiving combination chemotherapy.
- C. The client diagnosed with leukemia who has petechiae covering both anterior and posterior body surfaces.
- D. The client diagnosed with diffuse histolytic lymphoma who is to receive two (2) units of packed red blood cells.
Correct Answer: C
Rationale: Leukemia with extensive petechiae (C) indicates severe thrombocytopenia, requiring experienced assessment for bleeding. Radiation (A), chemotherapy (B), and transfusions (D) are less complex.
The client is placed on neutropenia precautions. Which information should the nurse teach the client?
- A. Shave with an electric razor and use a soft toothbrush.
- B. Eat plenty of fresh fruits and vegetables.
- C. Perform perineal care after every bowel movement.
- D. Some blood in the urine is not unusual.
Correct Answer: A
Rationale: Neutropenia precautions include electric razors and soft toothbrushes (A) to prevent bleeding/infection. Fresh produce (B) risks infection, perineal care (C) is routine, and hematuria (D) is abnormal.
A child who is being treated for leukemia develops stomatitis. Which of the following nursing care measures is essential?
- A. Using dental floss to clean the teeth
- B. Frequent cleaning of the mouth with an astringent mouthwash
- C. Use of an overbed cradle
- D. Swabbing the mouth with moistened cotton swabs
Correct Answer: D
Rationale: Swabbing the mouth with moistened cotton swabs gently cleans the mouth without irritating stomatitis. Flossing or astringent mouthwash may worsen irritation, and an overbed cradle is unrelated.
The client asks the nurse, 'They say I have cancer. How can they tell if I have Hodgkin's disease from a biopsy?' The nurse’s answer is based on which scientific rationale?
- A. Biopsies are nuclear medicine scans that can detect cancer.
- B. A biopsy is a laboratory test that detects cancer cells.
- C. It determines which kind of cancer the client has.
- D. The HCP takes a small piece out of the tumor and looks at the cells.
Correct Answer: C
Rationale: A biopsy identifies Hodgkin’s via Reed-Sternberg cells (C). It’s not a scan (A), not just a lab test (B), and involves microscopic cell analysis (D is partial but less precise).
The nurse is caring for a client diagnosed with sickle cell disease. Which should the nurse include in the client’s plan of care?
- A. Teach the client to limit fluids.
- B. Discuss interventions to maintain hydration.
- C. Measure the client’s calf for swelling.
- D. Have the client take narcotic pain medication every four (4) hours.
Correct Answer: B
Rationale: Hydration (B) prevents sickling in SCD. Limiting fluids (A) worsens crisis, calf swelling (C) is for DVT, and scheduled narcotics (D) risk dependency.