Nokea
The nurse completed teaching the client who had a bone marrow transplant (BMT). Which statement by the client indicates the client misunderstood the expected changes following a BMT?
- A. “I may gain weight from my immunosuppressant medication.”
- B. “Sterility can occur from the chemotherapy and radiation.”
- C. “I may have vision changes from the total body irradiation.”
- D. “Changes to my mouth could include a white, patchy tongue.”
Correct Answer: D
Rationale: A. A common side effect of immunosuppressant medications is weight gain. B. Sterility can occur as a result of chemotherapy and the total body irradiation after BMT. C. Changes in vision are common as a result of the total body irradiation after BMT. D. A white, patchy tongue is a sign of a fungal infection with Candidiasis albicans and would not be an expected change.
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The nurse is assessing an African American client diagnosed with sickle cell crisis. Which assessment datum is most pertinent when assessing for cyanosis in clients with dark skin?
- A. Assess the client’s oral mucosa.
- B. Assess the client’s metatarsals.
- C. Assess the client’s capillary refill time.
- D. Assess the sclera of the client’s eyes.
Correct Answer: A
Rationale: Oral mucosa (A) is the best site to assess cyanosis in dark skin, showing dusky color. Metatarsals (B) and sclera (D) are less reliable, and capillary refill (C) assesses perfusion.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients in a bone marrow transplantation unit. Which nursing task should the nurse delegate?
- A. Take the hourly vital signs on a client receiving blood transfusions.
- B. Monitor the infusion of antineoplastic medications.
- C. Transcribe the HCP’s orders onto the medication administration record (MAR).
- D. Determine the client’s response to the therapy.
Correct Answer: A
Rationale: Taking vital signs (A) is within UAP scope during transfusions. Monitoring chemo (B), transcribing orders (C), and evaluating response (D) require nursing judgment.
The nurse is caring for the following clients. Which client should the nurse assess first?
- A. The client whose partial thromboplastin time (PTT) is 38 seconds.
- B. The client whose hemoglobin is 14 g/dL and hematocrit is 45%.
- C. The client whose platelet count is 75,000 per cubic millimeter of blood.
- D. The client whose red blood cell count is 4.8 x 106/mm3.
Correct Answer: C
Rationale: Platelets 75,000 (C) indicate thrombocytopenia, risking bleeding, a priority. PTT 38 (A) is therapeutic, Hb/Hct (B) are normal, and RBC 4.8 (D) is normal.
The 24-year-old female client is diagnosed with idiopathic thrombocytopenic purpura (ITP). Which question would be important for the nurse to ask during the admission interview?
- A. Do you become short of breath during activity?'
- B. How heavy are your menstrual periods?'
- C. Do you have a history of deep vein thrombosis?'
- D. How often do you have migraine headaches?'
Correct Answer: B
Rationale: ITP causes bleeding; heavy menstrual periods (B) assess bleeding severity. Dyspnea (A), DVT (C), and migraines (D) are unrelated.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical unit. Which task should the nurse delegate to the UAP?
- A. Check on the bowel movements of a client diagnosed with melena.
- B. Take the vital signs of a client who received blood the day before.
- C. Evaluate the dietary intake of a client who has been noncompliant with eating.
- D. Shave the client diagnosed with severe hemolytic anemia.
Correct Answer: B
Rationale: Taking vital signs post-transfusion (B) is within UAP scope. Checking melena (A), evaluating diet (C), and shaving with anemia (D) require nursing judgment due to bleeding risks.