Nokea
The nurse assesses a client's oral cavity and makes the discovery shown in the photo below: What action by the nurse is most appropriate?
- A. Encourage the client to have genetic testing
- B. Instruct the client on high-fiber foods
- C. Place the client in neutropenic precautions
- D. Teach the client about cobalamin therapy
Correct Answer: D
Rationale: The condition shown is glossitis, characteristic of B12 deficiency anemia, treated with cobalamin (vitamin B12). Genetic testing, high-fiber foods, or neutropenic precautions are not relevant to this condition.
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A client with chronic anemia has had many blood transfusions. What medications does the nurse anticipate teaching the client about adding to the regimen? (Select all that apply.)
- A. Azacitidine (Vidaza)
- B. Darbepoetin alfa (Aranesp)
- C. Decitabine (Dacogen)
- D. Epoetin alfa (Epogen)
- E. Methylprednisolone (Solu-Medrol)
Correct Answer: B,D
Rationale: Darbepoetin alfa and epoetin alfa are red blood cell colony-stimulating factors that help increase red blood cell production. Azacitidine and decitabine are used for myelodysplastic syndromes, and methylprednisolone is a steroid not used for anemia.
The nurse instructor is best?
- A. Because of immunosuppression, the donor cells take over.
- B. In like a transfusion reaction because no perfect matches exist.
- C. The client's cells are fighting donor cells for dominance.
- D. The donor's cells are actually attacking the client's cells.
Correct Answer: D
Rationale: Graft versus host disease is an autoimmune-type process in which the donor cells recognize the client's cells as foreign and begin attacking them. The other answers are not accurate.
A client has frequent hospitalizations for leukemia and is worried about functioning as a parent to four small children. What action by the nurse would be most helpful?
- A. Assist the client to make sick day plans for household responsibilities.
- B. Help the client inform friends and family that they will have to help out.
- C. Refer the client to a social worker for family counseling.
- D. Provide information on community support groups.
Correct Answer: A
Rationale: Helping the client make sick day plans addresses their concern about parenting responsibilities during hospitalizations, offering practical support. Informing friends and family is less proactive, and while counseling or support groups may help, they are less immediate solutions.
A nurse working with clients with sickle cell disease (SCD) teaches about self-management to prevent exacerbation and sickle cell crises. What factors should clients be taught to avoid? (Select all that apply.)
- A. Dehydration
- B. Radiation
- C. Extreme stress
- D. High altitudes
- E. Pregnancy
Correct Answer: A,C,D,E
Rationale: Several factors cause red blood cells to sickle in SCD, including dehydration, extreme stress, high altitudes, and pregnancy, as they can trigger vaso-occlusive crises. Radiation is not a specific trigger unless related to extreme physical stress.
A nurse is caring for four clients with leukemia. After hand-off report, which client should the nurse see first?
- A. Client who had two bloody diarrhea stools this morning
- B. Client who has been premedicated for nausea prior to chemotherapy
- C. Client with a respiratory rate change from 18 to 22 breaths/min
- D. Client with an unchanged lesion to the lower right lateral malleolus
Correct Answer: A
Rationale: The client with two bloody diarrhea stools may be hemorrhaging in the gastrointestinal tract, indicating a potentially life-threatening condition requiring immediate assessment. The client with a respiratory rate change may have an infection or worsening anemia and should be seen next. The other two clients are not as urgent.