Nokea
The nurse administers iron using the Z track technique. What is the primary reason for administering iron via Z track?
- A. To prevent adverse reactions
- B. To prevent staining of the skin
- C. To improve the absorption rate
- D. To increase the speed of onset of action
Correct Answer: B
Rationale: The Z track technique prevents iron from leaking into subcutaneous tissue, reducing skin staining.
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Which concepts could the nurse identify for a client diagnosed with lymphoma? Select all that apply.
- A. Coping.
- B. Hematologic regulation.
- C. Tissue perfusion.
- D. Clotting.
- E. Clinical judgment.
Correct Answer: A,B,C,D
Rationale: Lymphoma involves coping (A) with diagnosis, hematologic regulation (B) via lymph dysfunction, perfusion (C) due to node obstruction, and clotting (D) from thrombocytopenia. Clinical judgment (E) is a nursing process, not a patient concept.
The client is diagnosed with chronic myeloid leukemia and leukocytosis. Which signs/symptoms would the nurse expect to find when assessing this client?
- A. Frothy sputum and jugular vein distention.
- B. Dyspnea and slight confusion.
- C. Right upper quadrant tenderness and nausea.
- D. Increased appetite and weight gain.
Correct Answer: B
Rationale: CML with leukocytosis causes fatigue, dyspnea, and confusion (B) from hyperviscosity. Sputum/JVD (A) suggest heart failure, RUQ/nausea (C) suggest liver issues, and appetite/weight gain (D) are unlikely.
The nurse is admitting a client with a diagnosis of rule-out Hodgkin's lymphoma. Which assessment data support this diagnosis?
- A. Night sweats and fever without 'chills.'
- B. Edematous lymph nodes in the groin.
- C. Malaise and complaints of an upset stomach.
- D. Pain in the neck area after a fatty meal.
Correct Answer: A
Rationale: Night sweats and fever (A) are classic Hodgkin’s B symptoms. Edematous nodes (B) are not typical (firm, non-tender), malaise/stomach (C) is nonspecific, and neck pain (D) suggests gallbladder issues.
The client diagnosed with sickle cell anemia comes to the emergency department complaining of joint pain throughout the body. The oral temperature is 102.4°F and the pulse oximeter reading is 91%. Which action should the emergency department nurse implement first?
- A. Request arterial blood gases STAT.
- B. Administer oxygen via nasal cannula.
- C. Start an IV with an 18-gauge angiocath.
- D. Prepare to administer analgesics as ordered.
Correct Answer: B
Rationale: SpO2 91% and fever suggest hypoxia in SCA crisis; oxygen via cannula (B) addresses this first. ABGs (A), IV (C), and analgesics (D) follow to confirm hypoxia, hydrate, and manage pain.
A coworker being oriented by another nurse states, “I’m confused; a physician told me that graft-versus-host disease (GVHD) symptoms were desirable for a particular client after a bone marrow transplant.” Which should be the nurse’s best response?
- A. “GVHD isn’t desirable. Maybe you heard the physician wrong.”
- B. “That’s interesting. Did the client have a gastrointestinal tumor?”
- C. “That’s right if the transplant involved using autologous stem cells.”
- D. “GVHD is sometimes desirable with a hematological malignancy.”
Correct Answer: D
Rationale: A. GVHD is desirable if the primary source is hematological. B. Bone marrow transplant is not a treatment for GI malignancies unless the primary source is hematological. C. GVHD does not occur when a person receives autologous (his or her own) cells during a transplant. D. GVHD is sometimes desirable with a hematological malignancy. The donor lymphocytes can mount a reaction against any lingering tumor cells and destroy them.