Nokea
The client is diagnosed with sickle cell crisis. The nurse is calculating the client’s intake and output (I&O) for the shift. The client had 20 ounces of water, eight (8) ounces of apple juice, three (3) cartons of milk with four (4) ounces each, 1,800 mL of IV fluids for the last 12 hours, and a urinary output of 1,200. What is the client’s total intake for this shift?
Correct Answer: 2840
Rationale: Oral intake: 20 oz water + 8 oz juice + (3 × 4 oz milk) = 36 oz. 1 oz = 30 mL, so 36 × 30 = 1,080 mL. IV fluids = 1,800 mL. Total intake = 1,080 + 1,800 = 2,840 mL. Output (1,200 mL) is not included.
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The client diagnosed with leukemia is being admitted for an induction course of chemotherapy. Which laboratory values indicate a diagnosis of leukemia?
- A. A left shift in the white blood cell (WBC) count differential.
- B. A large number of WBCs that decreases after the administration of antibiotics.
- C. An abnormally low hemoglobin (Hb) and hematocrit (Hct) level.
- D. Red blood cells (RBCs) that are larger than normal.
Correct Answer: C
Rationale: Leukemia causes bone marrow suppression, leading to low Hb/Hct (C). Left shift (A) indicates infection, antibiotic response (B) suggests infection, and large RBCs (D) indicate megaloblastic anemia.
An 8-year-old boy is admitted to the unit with a diagnosis of acute lymphocytic leukemia. During a routine physical exam, numerous ecchymotic areas were noted on his body. The parent reported that the child has been more tired than usual personally more tired than usual lately. The parent says that the child has had a cold for the last several weeks and asks if this is related to the leukemia. The nurse's response is based on the knowledge that:
- A. leukemia causes a decrease in the number of normal white blood cells in the body.
- B. a chronic infection such as the child has had makes a child more likely to develop leukemia.
- C. the virus responsible for colds is thought to cause leukemia.
- D. having an infection prior to the onset of leukemia is merely a coincidence.
Correct Answer: A
Rationale: Leukemia reduces normal white blood cells, impairing infection fighting, which may explain the prolonged cold. Infections do not cause leukemia.
The client hospitalized with cervical cancer is receiving radiation therapy via a temporary radioactive cervical implant. Which nursing actions would be appropriate for this client?
- A. Minimize anxiety and confusion by telling the client the reason for the time and distance limitations.
- B. Utilize the unit’s common film badge that indicates the cumulative radiation exposure while caring for the client.
- C. Organize cares to limit the amount of time spent in direct contact with the client receiving internal radiation.
- D. Use shielding if delivering care within close proximity to the client, such as checking placement of the implant.
- E. Encourage frequent oral care with warm saline rinses to help with irritation of oral mucosa.
Correct Answer: A, C, D
Rationale: A. Safety measures for caring for someone undergoing internal radiation therapy include limiting time, distance, and shielding. It would be important to make the client aware of the time and distance limitations to help ease anxiety. B. A personal, not shared, film badge should be worn so cumulative radiation exposure can be measured accurately. C. Organizing care would be appropriate in order to limit the exposure to radiation. D. Shielding is important for keeping caregivers safe from potential radiation exposure. E. The implant is placed in the vaginal canal and has no impact on oral mucosa.
The nurse teaches a coworker about the treatment for hemophilia. The nurse instructs that the treatment will likely include periodic self-administration of which component?
- A. Platelets
- B. Whole blood
- C. Factor concentrates
- D. Fresh frozen plasma
Correct Answer: C
Rationale: A. Platelets do not contain the deficient clotting factors. B. Although whole blood contains the deficient factors, periodic administration of factor concentrates are safer. C. A person with hemophilia A is deficient in factor VIII; hemophilia B, factor IX; and von Willebrand’s hemophilia, the von Willebrand’s factor and factor VIII. Recombinant forms of the factors are available for the client to self-administer intravenously at home. D. Although fresh frozen plasma contains the deficient factors, periodic administration of factor concentrates are safer.
The nurse is caring for a client diagnosed with acute myeloid leukemia. Which assessment data warrant immediate intervention?
- A. T 99, P 102, R 22, and BP 132/68.
- B. Hyperplasia of the gums.
- C. Weakness and fatigue.
- D. Pain in the left upper quadrant.
Correct Answer: D
Rationale: Left upper quadrant pain (D) suggests splenic rupture, a life-threatening AML complication. Vitals (A) are stable, gum hyperplasia (B) is expected, and fatigue (C) is common.