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The client, who underwent a right mastectomy with lymph node dissection, is being admitted to a nursing unit from the PACU. When settling the client in bed, which action by the NA requires the nurse to intervene?
- A. Placing a blood pressure cuff on the left arm for vital signs
- B. Taping a sign to the side rail stating no IV or lab draws on the right
- C. Elevating the bed to 90 degrees and keeping the right arm dependent
- D. Asking if the client feels ready to allow family to enter the room
Correct Answer: C
Rationale: A. BPs, venipunctures, and injections should not be done on the affected arm, so taking the BP on the left arm would be appropriate. B. It would be appropriate for the NA to tape a sign at the side rail to remind others of the restrictions following a mastectomy. C. The client should be placed in a semi-Fowler’s position with the arm on the affected side elevated on a pillow to promote restoring arm function and to prevent arm edema. D. It would be beneficial for the NA and nurse to be sensitive to the client’s readiness for family presence.
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The nurse is preparing to administer epoetin alfa to the client who has chemotherapy-associated anemia. The nurse recognizes the need to consult with the HCP before administration when the client makes which statements?
- A. “I spend most of my days lying on the couch.”
- B. “I usually eat a lot of salads for my main meals.”
- C. “I seem to have an aversion to eating eggs right now.”
- D. “I developed a blood clot in my leg on my last admission.”
- E. “I hope this helps so I don’t have to have a blood transfusion.”
Correct Answer: A, D
Rationale: Erythropoiesis-stimulating agents, such as epoetin alfa (Epogen), can cause thromboembolic events. It would be concerning if the client had limited activity because this could further increase the client’s risk of a thromboembolic event. B. Dark green, leafy vegetables are high in iron and help with Hgb synthesis and therefore would be beneficial. C. Eggs are high in iron, but there are other food sources high in iron that the client can consume if an aversion exists. D. A history of a thromboembolic event and use of epoetin alfa increase the client’s risk for another thromboembolic event. E. The use of epoetin alfa is recommended as a treatment option for clients with chemotherapy-associated anemia and an Hgb concentration that is approaching, or has fallen below, 10 g/dL, to increase the Hgb level and decrease the need for a transfusion.
A 19-year-old college student reports to the health service with a sore throat, malaise, and fever of four days in duration. Examination shows cervical lymphadenopathy and splenomegaly. Temperature is 103°F. Blood is positive for heterophil antibody agglutination test. Which condition does the nurse expect this student to have?
- A. Streptococcal sore throat
- B. Infectious mononucleosis
- C. Rubella
- D. Influenza
Correct Answer: B
Rationale: The symptoms and positive heterophil antibody test are diagnostic for infectious mononucleosis.
The nurse writes a nursing problem of 'altered nutrition' for a client diagnosed with leukemia who has received a treatment regimen of chemotherapy and radiation. Which nursing intervention should be implemented?
- A. Administer an antidiarrheal medication prior to meals.
- B. Monitor the client's serum albumin levels.
- C. Assess for signs and symptoms of infection.
- D. Provide skin care to irradiated areas.
Correct Answer: B
Rationale: Altered nutrition requires monitoring serum albumin (B) to assess protein status. Antidiarrheals (A) are symptom-specific, infection (C) is unrelated, and skin care (D) addresses radiation effects.
The nurse identified clotting as a concept related to sickle cell disease. Which intervention should the nurse implement?
- A. Assess for cerebrovascular symptoms.
- B. Keep the head of the bed elevated.
- C. Order a 2,000-mg sodium diet.
- D. Apply antiembolism stockings.
Correct Answer: A
Rationale: SCD causes vaso-occlusion; assessing cerebrovascular symptoms (A) detects stroke risk. HOB elevation (B) is for ICP, sodium diet (C) is for hypertension, and stockings (D) are for DVT.
The client with hemophilia A is experiencing hemarthrosis. Which intervention should the nurse recommend to the client?
- A. Alternate aspirin and acetaminophen to help with the pain.
- B. Apply cold packs for 24 to 48 hours to the affected area.
- C. Perform active range-of-motion exercise on the extremity.
- D. Put the affected extremity in the dependent position.
Correct Answer: B
Rationale: Hemarthrosis requires cold packs (B) to reduce bleeding/swelling. Aspirin (A) increases bleeding, ROM (C) worsens damage, and dependent position (D) increases swelling.