Nokea
The nurse expects the plan of care for a patient with leukemia to focus on which aspect of care?
- A. Prevention of abnormal clotting
- B. Promotion of mobility activities
- C. Frequent transfusions of plasma
- D. Prevention of infectious diseases
Correct Answer: D
Rationale: The white blood cells are abnormal and not functioning well with leukemia, therefore, prevention of infection is a priority of care. A lack of platelets is seen with leukemia, causing excessive bleeding, not abnormal clotting. Promoting mobility is not a priority of care with leukemia. Plasma transfusions are not associated with care of a patient with leukemia.
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A patient has been diagnosed with pernicious anemia. When reinforcing instructions, the nurse explains this disorder results from which process?
- A. Poor nutritional intake of iron
- B. Lack of the intrinsic factor
- C. Blood loss due to hemorrhage
- D. Excess production of red blood cells
Correct Answer: B
Rationale: With pernicious anemia, the body lacks the intrinsic factor. Iron deficiency anemia is caused by poor nutritional iron intake. Blood loss associated anemia is due to hemorrhage. Pernicious anemia is not associated with excess production of red blood cells.
In caring for a patient with multiple myeloma, which should the nurse prioritize from the plan of care?
- A. Limit fluid intake to less than 1000 mL/day
- B. Closely supervise and assist when ambulating
- C. Strain all urine for kidney crystals
- D. Limit the use of an analgesic
Correct Answer: B
Rationale: Because of the constant threat of pathologic fractures, ambulation should be carefully supervised and assisted. Fluids are not restricted. Uric acid is increased and may crystalize in the kidney, but straining is not necessary. Analgesia is necessary for relief of bone pain.
When reinforcing instructions for the patient taking an oral liquid iron preparation, which should the nurse include?
- A. Information relative to taking the iron with milk
- B. Information relative to the bowel movement color changing to dark red
- C. Information relative to taking preparation through a straw to prevent staining of teeth
- D. Information relative to taking a drug with meals or a snack
Correct Answer: C
Rationale: Liquid iron preparations should be drunk through a straw to prevent tooth staining. All oral iron preparations should be taken before meals. Dairy products interfere with the absorption of iron.
Which is the first step in the process of hemostasis?
- A. Prothrombin converts to thrombin
- B. Formation of thrombin
- C. Formation of fibrin
- D. Trapping of RBC and platelets
- E. Clot
- F. Release of thromboplastin from platelets
Correct Answer: F
Rationale: Thromboplastin is released from the platelets, which acts with calcium to form thrombin; fibrin is formed, which traps red cells and platelets to make the clot.
Which mandatory practice is the most effective and significant nursing practice to prevent the spread of infection for a patient with agranulocytosis?
- A. Strict and frequent hand washing by all people having contact with the patient
- B. Placement of patients in private rooms with high-efficiency particulate air (HEPA) filtration
- C. Administration of combinations of prophylactic antibiotics
- D. Creation of a 'sterile' environment for the patient with the use of laminar airflow rooms
Correct Answer: A
Rationale: Meticulous hand washing by medical and nursing personnel and strict asepsis are mandatory.