Nokea
The client is diagnosed with polycythemia vera. The nurse would prepare to perform which intervention?
- A. Type and crossmatch for a transfusion.
- B. Assess for petechiae and purpura.
- C. Perform phlebotomy of 500 mL of blood.
- D. Monitor for low hemoglobin and hematocrit.
Correct Answer: C
Rationale: Polycythemia vera requires phlebotomy (C) to reduce blood viscosity. Transfusions (A) worsen hyperviscosity, petechiae (B) are for thrombocytopenia, and Hb/Hct (D) are elevated.
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The nurse discusses the self-care guidelines to minimize the side effects of radiation on the skin. Which actions to reduce radiation skin reactions should the nurse explain to the client?
- A. Wear loose-fitting, soft clothing over the treated skin.
- B. Use a straight-edged razor to shave hair in the treated area.
- C. Swim only in swimming pools to avoid stagnant water.
- D. Use only skin-care products suggested by the radiation staff.
- E. Apply skin products immediately after radiation treatment.
- F. Wash treated area gently with lukewarm water and mild soap.
Correct Answer: A, D, F,
Rationale: Wearing loose-fitting, soft clothing over the treated skin is a recommended skin-care activity to reduce radiation skin reactions. B. The use of an electric, not a straight-edged, razor for shaving a treated area is recommended. C. Clients are advised to avoid swimming in chlorinated water. D. Using only skin-care products suggested by the radiation staff is a recommended skin-care activity to reduce radiation skin reactions. E. Clients are advised to delay the application of skin-care products within 4 hours of radiation treatment. F. Washing the treated area gently with lukewarm water and mild soap is a recommended skin-care activity to reduce radiation skin reactions.
The nurse assesses the client diagnosed with acute myeloid leukemia. Which finding should be the nurse’s priority for implementing interventions?
- A. Pain from mucositis and oral tissue injury
- B. Weakness and fatigue with slight activity
- C. T 99°F, P 100, R 22, BP 132/64 mm Hg
- D. Ecchymosis and petechiae noted on arms
Correct Answer: A
Rationale: A. Pain control is priority. The altered VS (other than temperature) could be related to pain. B. Weakness and fatigue are due to anemia and also the disease process. It is important to allow rest, but if pain is not controlled the client may not be able to rest. C. The temperature warrants further monitoring because it could indicate a developing infection; the other VS may decrease if pain is controlled. D. Ecchymosis and petechiae are associated with low platelet counts. The nurse should check the laboratory report for the platelet level, but this is an assessment and not an intervention.
The client diagnosed with leukemia is scheduled for bone marrow transplantation. Which interventions should be implemented to prepare the client for this procedure? Select all that apply.
- A. Administer high-dose chemotherapy.
- B. Teach the client about autologous transfusions.
- C. Have the family members' HLA typed.
- D. Monitor the complete blood cell count daily.
- E. Provide central line care per protocol.
Correct Answer: A,C,D,E
Rationale: High-dose chemotherapy (A) ablates marrow, HLA typing (C) identifies donors, CBC monitoring (D) tracks counts, and central line care (E) prevents infection. Autologous transfusions (B) are irrelevant (donor marrow used).
The client is experiencing pain due to cancer treatment- The client tells the nurse, “Methadone has always worked well for me in the past.” Which effects of methadone should the nurse consider when administering methadone?
- A. Has a long half-life and high level of potency
- B. May cause an increase in BP and confusion
- C. Causes severe allergic reactions and liver failure
- D. Has active metabolites, but it is well tolerated
Correct Answer: A
Rationale: bg
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.