Nokea
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.
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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 diagnosed with leukemia has central nervous system involvement. Which instruction should the nurse teach?
- A. Sleep with the HOB elevated to prevent increased intracranial pressure.
- B. Take an analgesic medication for pain only when the pain becomes severe.
- C. Explain radiation therapy to the head may result in permanent hair loss.
- D. Discuss end-of-life decisions prior to cognitive deterioration.
Correct Answer: D
Rationale: CNS leukemia risks cognitive decline; discussing end-of-life decisions (D) is critical before deterioration. HOB elevation (A) is for ICP, not routine, analgesics (B) should be proactive, and hair loss (C) is secondary.
A home-care nurse is following up with the client who was diagnosed with liver cancer 3 months ago. Which assessment information should the nurse communicate to the HCP?
- A. Client is weak and pale and remained in bed throughout the visit
- B. Client’s weight has remained unchanged since the previous visit.
- C. Client reports itching is relieved with diphenhydramine cream.
- D. Client’s pain level averages a 7 on a 0 to 10 scale with scheduled opioids.
Correct Answer: D
Rationale: A. Finding that the client with liver cancer is weak and pale would be important to document, but it does not warrant immediate communication to the HCP because it may be expected. B. The client’s weight being stable would not necessitate communication to the HCP, but a significant decrease would. C. Abdominal itching may occur with liver cancer, but the fact that it is relieved with diphenhydramine (Benadryl) is positive and would not necessitate a call to the HCP. D. The client’s pain level is high and does not seem to be controlled with the current opioid schedule. The nurse should notify the HCP to request a change in analgesic medication, dosing schedule, or administration route.
The client has undergone a lymph node biopsy to differentiate between Hodgkin’s and non-Hodgkin’s lymphoma. After reviewing the client’s lymph node biopsy results, which revealed that the client has Hodgkin’s lymphoma, the nurse should obtain which educational brochure?
- A. The brochure that includes an explanation of an elevated reticulocyte count
- B. The brochure that includes an explanation of CA-125 tumor markers
- C. The brochure that includes an explanation of an elevated WBC count
- D. The brochure that includes an explanation about Reed-Sternberg cells
Correct Answer: D
Rationale: A. Reticulocytes are found in a CBC, not from a lymph node biopsy, and are not indicative of either Hodgkin’s or non-Hodgkin’s lymphoma. B. CA-125 tumor markers are sometimes used in the management of ovarian cancer. C. WBCs are collected from a complete blood panel, not a lymph node biopsy, and could be indicative of other lymphomas and/or leukemia. D. The nurse should obtain the brochure that explains about Reed-Sternberg cells. The main diagnostic feature of Hodgkin’s lymphoma is the presence of Reed-Sternberg cells in a lymph node biopsy.
The client diagnosed with anemia begins to complain of dyspnea when ambulating in the hall. Which intervention should the nurse implement first?
- A. Apply oxygen via nasal cannula.
- B. Get a wheelchair for the client.
- C. Assess the client’s lung fields.
- D. Assist the client when ambulating in the hall.
Correct Answer: B
Rationale: Dyspnea in anemia suggests low oxygen-carrying capacity; a wheelchair (B) prevents exertion while further assessment occurs. Oxygen (A), lung assessment (C), and assistance (D) follow.