Nokea
The client is diagnosed with hereditary spherocytosis. Which treatment/procedure would the nurse prepare the client to receive?
- A. Bone marrow transplant.
- B. Splenectomy.
- C. Frequent blood transfusions.
- D. Liver biopsy.
Correct Answer: B
Rationale: Spherocytosis causes hemolytic anemia; splenectomy (B) reduces RBC destruction. BMT (A) is for leukemia, transfusions (C) are supportive, and liver biopsy (D) is unrelated.
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A child with leukemia bruises easily. This is most likely due to which of the following?
- A. Decreased fibrinogen levels
- B. Excessive clotting elsewhere in the body
- C. Decreased platelets
- D. Decreased erythrocytes
Correct Answer: C
Rationale: Leukemia causes bone marrow failure, leading to decreased platelets, which results in easy bruising.
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.
The client has a hematocrit of 22.3% and a hemoglobin of 7.7 g/dL. The HCP has ordered two (2) units of packed red blood cells to be transfused. Which interventions should the nurse implement? Select all that apply.
- A. Obtain a signed consent.
- B. Initiate a 22-gauge IV.
- C. Assess the client’s lungs.
- D. Check for allergies.
- E. Hang a keep-open IV of D5W.
Correct Answer: A,C,D
Rationale: Consent (A), lung assessment (C), and allergy checks (D) ensure safe transfusion. A 22-gauge IV (B) is too small (18-gauge preferred), and D5W (E) is incompatible (use NS).
A child who has hemophilia is admitted to the hospital with a swollen knee joint. He is complaining of severe pain. What is the priority of nursing care for this child upon admission?
- A. Maintain joint function
- B. Use a bed cradle
- C. Administer aspirin as needed for pain
- D. Encourage fluids
Correct Answer: B
Rationale: Using a bed cradle reduces pressure on the swollen, painful joint, prioritizing pain relief and comfort during a bleeding episode.
Which test is considered diagnostic for Hodgkin's lymphoma?
- A. A magnetic resonance image (MRI) of the chest.
- B. A computed tomography (CT) scan of the cervical area.
- C. An erythrocyte sedimentation rate (ESR).
- D. A biopsy of the cervical lymph nodes.
Correct Answer: D
Rationale: Lymph node biopsy (D) diagnoses Hodgkin’s via Reed-Sternberg cells. MRI/CT (A, B) stage disease, ESR (C) is nonspecific.