Nokea
The client who is receiving doxorubicin for the first time to treat multiple myeloma develops flushing, facial swelling, headache, chills, and back pain. Which statement made by the nurse is best?
- A. “These symptoms usually resolve in 1 day and are limited to the first dose.”
- B. “These are signs of toxicity; you may want to consider refusing treatment.”
- C. “I can give you ondansetron prescribed prn now to alleviate these symptoms.”
- D. “Side effects occur with chemotherapy, but focus on your cancer being cured.”
Correct Answer: A
Rationale: A. This response is best. The nurse informs the client correctly that the symptoms of doxorubicin (Adriamycin) are limited to the first dose. B. The nurse is providing unsolicited advice. C. Ondansetron (Zofran) is an antiemetic and will not alleviate all of the symptoms. D. This response belittles the client’s symptoms. There is no cure for multiple myeloma. Treatment will control the illness and maintain the client’s level of functioning for several years or more.
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The 24-year-old female client is diagnosed with idiopathic thrombocytopenic purpura (ITP). Which question would be important for the nurse to ask during the admission interview?
- A. Do you become short of breath during activity?'
- B. How heavy are your menstrual periods?'
- C. Do you have a history of deep vein thrombosis?'
- D. How often do you have migraine headaches?'
Correct Answer: B
Rationale: ITP causes bleeding; heavy menstrual periods (B) assess bleeding severity. Dyspnea (A), DVT (C), and migraines (D) are unrelated.
A child who has leukemia is to have a bone marrow biopsy performed. How will the child be positioned for this procedure?
- A. On his side with the top knee flexed
- B. Prone
- C. Modified Trendelenburg position
- D. On his back with his head elevated 30 degrees
Correct Answer: B
Rationale: The prone position is used for a bone marrow biopsy from the iliac crest to access the site safely.
The client who received 50 mL from a unit of whole blood has low back pain. In response to this client’s symptom, which action should be taken by the nurse first?
- A. Reposition the client.
- B. Assess the pain further.
- C. Administer an analgesic.
- D. Stop the blood transfusion.
Correct Answer: D
Rationale: A. Repositioning focuses on treating the client’s back pain and not on the blood transfusion, which could be the cause of the back pain. B. Further assessment should occur after stopping the blood transfusion. C. The client may need an analgesic for pain control, but this should occur after stopping the blood transfusion. D. Low back pain is a symptom of a potentially life-threatening acute hemolytic reaction. The pain is caused from agglutination of RBCs in the kidneys and renal vasoconstriction. Hemolytic reactions occur most often within the first 50 mL of the infusion.
The nurse is assessing an African American client diagnosed with sickle cell crisis. Which assessment datum is most pertinent when assessing for cyanosis in clients with dark skin?
- A. Assess the client’s oral mucosa.
- B. Assess the client’s metatarsals.
- C. Assess the client’s capillary refill time.
- D. Assess the sclera of the client’s eyes.
Correct Answer: A
Rationale: Oral mucosa (A) is the best site to assess cyanosis in dark skin, showing dusky color. Metatarsals (B) and sclera (D) are less reliable, and capillary refill (C) assesses perfusion.
A 1-year-old is admitted to the hospital with sickle cell anemia in crisis. Upon admission, which therapy will assume priority?
- A. Fluid administration
- B. Exchange transfusion
- C. Anticoagulant
- D. IM administration of iron and folic acid
Correct Answer: A
Rationale: Fluid administration is the priority in sickle cell crisis to prevent dehydration and reduce blood viscosity, which can worsen sickling.