Nokea
The client with Hodgkin’s lymphoma receives radiation treatments. The nurse should monitor the client for which specific symptoms of radiation pneumonitis?
- A. Tachypnea, hypotension, and fever
- B. Cough, elevated temperature, and dyspnea
- C. Bradypnea, cough, and decreased urine output
- D. Cough, tachycardia, and altered mental status
Correct Answer: B
Rationale: A. Hypotension is a symptom that is not common in radiation pneumonitis. B. Cough, fever, and dyspnea are classic symptoms in radiation pneumonitis due to a decrease in the surfactant in the lung. C. Decreased urine output is a symptom that is not common in radiation pneumonitis. D. Altered mental status is a symptom that is not common in radiation pneumonitis.
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When reviewing the morning serum laboratory results of the client with multiple myeloma, the nurse sees that the total calcium level is 13.2 mEq/L. Which interventions, if prescribed by the HCP, should the nurse plan to implement?
- A. Encourage fluid intake.
- B. Maintain strict bedrest.
- C. Administer furosemide IV.
- D. Give allopurinol by mouth.
- E. Offer foods high in calcium.
Correct Answer: C
Rationale: A, C: A. Adequate hydration dilutes calcium and prevents precipitates from causing renal tubular obstruction. B. The client with multiple myeloma is encouraged to ambulate because weight-bearing activities can help the bone resorb some calcium as well as prevent thrombosis that can accompany immobility. C. Furosemide (Lasix) given IV can promote the excretion of calcium when hypercalcemia exists due to multiple myeloma. D. Allopurinol (Zyloprim) may be administered to reduce the hyperuricemia that can accompany multiple myeloma, not the hypercalcemia. E. The serum calcium level is elevated (normal is 9–10.5 mg/dL). Foods high in calcium would not be offered. However, limiting the intake of foods high in calcium will not make any difference to the elevated calcium level that is caused by cancer.
At 1000 hours, the nurse is documenting the administration of 275 mL of compatible platelets, unit number XR123. Which information should the nurse document?
- A. One unit blood was administered over 4 hours.
- B. Platelet XR123 double-checked before infusion.
- C. No transfusion reactions noted during infusion.
- D. D5W infused with platelets to prevent clumping.
- E. Completed 275 mL of platelet infusion started at 0830.
Correct Answer: B, C, E,A.
Rationale: This documents an incomplete blood type, and platelets are unlikely to be administered over 4 hours. B. Documentation should include the type of product infused (platelets), product number (compatible platelets were ordered), and that it was double-checked. C. Documentation should include any adverse reactions. D. Only 0.9% NaCl should be used when administering blood or blood products, and usually only to purge the line before and after administration. E. Documentation should include volume infused. Platelets should be infused as fast as the client can tolerate the infusion to diminish clumping.
The client is hospitalized with a diagnosis of sickle cell crisis. Which findings should prompt the nurse to consider that the client is ready for discharge?
- A. Leukocyte count is at 7500/mm3
- B. Describes the importance of keeping warm
- C. Pain controlled at 2 on a 0 to 10 scale with analgesics
- D. Has not had chest pain or dyspnea for past 24 hours
- E. Blood transfusions effective in diminishing cell Sickling
- F. Hydroxyurea effective in suppressing leukocyte formation
Correct Answer: A, B, C, D
Rationale: leukocyte count of 7500/mm3 is within normal range (5000 to 10,000/mm3 indicates the absence of an infection). B. Keeping warm and avoiding chills will help to prevent infection. Cold causes vasoconstriction, slowing blood flow and aggravating the Sickling process. C. Acute pain is due to tissue hypoxia from the agglutination of sickled cells within blood vessels. D. The absence of symptoms of complication such as acute chest syndrome and pulmonary hypertension indicates readiness for discharge. E. RBC transfusions may help to prevent complications, but transfusions do not alter the person’s body from producing the deformed erythrocytes. F. Hydroxyurea (Hydrea) can decrease the permanent formation of sickled cells. A side effect (not therapeutic effect) of hydroxyurea is suppression of leukocyte formation.
The nurse is planning the care of a client diagnosed with aplastic anemia. Which interventions should be taught to the client? Select all that apply.
- A. Avoid alcohol.
- B. Pace activities.
- C. Stop smoking.
- D. Eat a balanced diet.
- E. Use a safety razor.
Correct Answer: A,B,C,D
Rationale: Avoiding alcohol (A), pacing activities (B), stopping smoking (C), and balanced diet (D) support aplastic anemia management. Safety razors (E) risk bleeding due to thrombocytopenia.
The client diagnosed with sickle cell disease is experiencing a vaso-occlusive crisis. Which priority interventions should the nurse implement?
- A. Maintain IV fluids and administer pain medication prn.
- B. Encourage frequent ambulation in the hallways.
- C. Administer oxygen via nasal cannula at 10 LPM.
- D. Monitor the client’s red blood cell count every four (4) hours.
Correct Answer: A
Rationale: IV fluids and pain medication (A) prevent sickling and manage vaso-occlusive crisis pain. Ambulation (B) risks hypoxia, 10 LPM oxygen (C) is excessive, and RBC monitoring (D) is not primary.