Nokea
The client is scheduled to have a total hip replacement in two (2) months and has chosen to prepare for autologous transfusions. Which medication would the nurse administer to prepare the client?
- A. Prednisone, a glucocorticoid.
- B. Zithromax, an antibiotic.
- C. Ativan, a tranquilizer.
- D. Epogen, a biologic response modifier.
Correct Answer: D
Rationale: Epogen (D) stimulates RBC production for autologous donation. Prednisone (A), Zithromax (B), and Ativan (C) are unrelated.
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Fifteen minutes after the nurse has initiated a transfusion of packed red blood cells, the client becomes restless and complains of itching on the trunk and arms. Which intervention should the nurse implement first?
- A. Collect urine for analysis.
- B. Notify the laboratory of the reaction.
- C. Administer diphenhydramine, an antihistamine.
- D. Stop the transfusion at the hub.
Correct Answer: D
Rationale: Restlessness/itching suggest a transfusion reaction; stopping at the hub (D) prevents further reaction. Urine collection (A), notification (B), and Benadryl (C) follow.
The nurse is discharging a client diagnosed with anemia. Which discharge instruction should the nurse teach?
- A. Take the prescribed iron until it is completely gone.
- B. Monitor pulse and blood pressure at a local pharmacy weekly.
- C. Have a complete blood count checked at the HCP’s office.
- D. Perform isometric exercise three (3) times a week.
Correct Answer: C
Rationale: Multiple Choice CBC checks (C) monitor anemia recovery. Taking iron indefinitely (A) depends on cause, BP/pulse checks (B) are nonspecific, and isometric exercise (D) may strain low oxygen capacity.
The nurse is completing a care plan for a client diagnosed with leukemia. Which independent problem should be addressed?
- A. Infection.
- B. Anemia.
- C. Nutrition.
- D. Grieving.
Correct Answer: A
Rationale: Infection (A) is critical in leukemia due to neutropenia, requiring independent nursing actions (e.g., hygiene). Anemia (B), nutrition (C), and grieving (D) are collaborative or secondary.
Which collaborative treatment would the nurse anticipate for the client diagnosed with DIC?
- A. Administer oral anticoagulants.
- B. Prepare for plasmapheresis.
- C. Administer frozen plasma.
- D. Calculate the intake and output.
Correct Answer: C
Rationale: Frozen plasma (C) replaces clotting factors in DIC. Oral anticoagulants (A) worsen bleeding, plasmapheresis (B) is rare, and I&O (D) is routine.
The client is diagnosed with chronic lymphocytic leukemia (CLL) after routine laboratory tests during a yearly physical. Which is the scientific rationale for the random nature of discovering the illness?
- A. CLL is not serious, and clients die from other causes first.
- B. There are no symptoms with this form of leukemia.
- C. This is a childhood illness and is self-limiting.
- D. In early stages of CLL, the client may be asymptomatic.
Correct Answer: D
Rationale: Early CLL is often asymptomatic (D), detected via routine labs. CLL is serious (A), has symptoms later (B), and is adult-onset (C), not self-limiting.