Nokea
The client is diagnosed with chronic myeloid leukemia and leukocytosis. Which signs/symptoms would the nurse expect to find when assessing this client?
- A. Frothy sputum and jugular vein distention.
- B. Dyspnea and slight confusion.
- C. Right upper quadrant tenderness and nausea.
- D. Increased appetite and weight gain.
Correct Answer: B
Rationale: CML with leukocytosis causes fatigue, dyspnea, and confusion (B) from hyperviscosity. Sputum/JVD (A) suggest heart failure, RUQ/nausea (C) suggest liver issues, and appetite/weight gain (D) are unlikely.
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The nurse writes a diagnosis of altered tissue perfusion for a client diagnosed with anemia. Which interventions should be included in the plan of care? Select all that apply.
- A. Monitor the client’s hemoglobin and hematocrit.
- B. Move the client to a room near the nurse’s desk.
- C. Limit the client’s dietary intake of green vegetables.
- D. Assess the client for numbness and tingling.
- E. Allow for rest periods during the day for the client.
Correct Answer: A,D,E
Rationale: Monitoring Hb/Hct (A), assessing numbness/tingling (D), and rest periods (E) address perfusion in anemia. Proximity to desk (B) is nonspecific, and limiting greens (C) is for anticoagulation, not anemia.
When planning care for a client who is HIV positive, the nurse should do what?
- A. Teach persons coming in contact with the client to wear a gown and mask at all times
- B. Teach persons to wear gloves when handling any of the client's body fluids
- C. Restrict visitors to immediate family
- D. Encourage the client to stay away from other persons as much as possible
Correct Answer: B
Rationale: Wearing gloves when handling body fluids follows standard precautions to prevent HIV transmission. Gowns and masks are not always necessary, and restricting visitors or isolating the client is not required.
The client, who underwent a right mastectomy with lymph node dissection, is being admitted to a nursing unit from the PACU. When settling the client in bed, which action by the NA requires the nurse to intervene?
- A. Placing a blood pressure cuff on the left arm for vital signs
- B. Taping a sign to the side rail stating no IV or lab draws on the right
- C. Elevating the bed to 90 degrees and keeping the right arm dependent
- D. Asking if the client feels ready to allow family to enter the room
Correct Answer: C
Rationale: A. BPs, venipunctures, and injections should not be done on the affected arm, so taking the BP on the left arm would be appropriate. B. It would be appropriate for the NA to tape a sign at the side rail to remind others of the restrictions following a mastectomy. C. The client should be placed in a semi-Fowler’s position with the arm on the affected side elevated on a pillow to promote restoring arm function and to prevent arm edema. D. It would be beneficial for the NA and nurse to be sensitive to the client’s readiness for family presence.
The client receiving a unit of PRBCs begins to chill and develops hives. Which action should be the nurse’s first response?
- A. Notify the laboratory and health-care provider.
- B. Administer the histamine-1 blocker, Benadryl, IV.
- C. Assess the client for further complications.
- D. Stop the transfusion and change the tubing at the hub.
Correct Answer: D
Rationale: Chills/hives suggest a transfusion reaction; stopping the transfusion at the hub (D) prevents further reaction. Assessment (C), Benadryl (B), and notification (A) follow.
The nurse is admitting a client with a diagnosis of rule-out Hodgkin's lymphoma. Which assessment data support this diagnosis?
- A. Night sweats and fever without 'chills.'
- B. Edematous lymph nodes in the groin.
- C. Malaise and complaints of an upset stomach.
- D. Pain in the neck area after a fatty meal.
Correct Answer: A
Rationale: Night sweats and fever (A) are classic Hodgkin’s B symptoms. Edematous nodes (B) are not typical (firm, non-tender), malaise/stomach (C) is nonspecific, and neck pain (D) suggests gallbladder issues.