Nokea
The nurse has identified the concept of cellular deviation for a client diagnosed with chronic myelogenous leukemia. Which intervention should the nurse implement? Select all that apply.
- A. Screen visitors for infection before allowing them to enter the room.
- B. Assess the client’s vital signs every four (4) hours.
- C. Do not allow fresh fruits and vegetables on diet trays.
- D. Monitor the client’s white blood cell count.
- E. Place the client on droplet isolation.
- F. Check the client’s bone marrow results daily.
Correct Answer: A,C,D
Rationale: Screening visitors (A), avoiding fresh produce (C), and monitoring WBCs (D) reduce infection risk in CML. Vitals (B) are routine, droplet isolation (E) is excessive, and daily bone marrow (F) is impractical.
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Which nursing interventions should the nurse implement when caring for a client diagnosed with hemophilia A? Select all that apply.
- A. Instruct the client to use a razor blade to shave.
- B. Avoid administering enemas to the client.
- C. Encourage participation in noncontact sports.
- D. Teach the client how to apply direct pressure if bleeding occurs.
- E. Explain the importance of not flossing the gums.
Correct Answer: B,C,D
Rationale: Avoiding enemas (B), noncontact sports (C), and teaching pressure (D) prevent bleeding in hemophilia. Razor blades (A) and avoiding flossing (E) increase bleeding risk.
A toddler has been treated for sickle cell crisis. The crisis subsides, and the child improves. Which statement is essential for the nurse to include in the discharge teaching?
- A. Your child will bruise easily. Do not let your child bump into things.
- B. Notify the physician immediately if your child develops a fever.
- C. Your child will need special help with feeding.
- D. Observe your child frequently for difficulty breathing.
Correct Answer: B
Rationale: Fevers can cause dehydration and trigger sickling, leading to a crisis, making it essential to notify the physician immediately.
The nurse is caring for the client following a total laryngectomy for treatment of laryngeal cancer. The nurse should plan consultations with which members of the multidisciplinary team?
- A. Physical therapist
- B. Dietitian
- C. Speech therapist
- D. Dentist
- E. Occupational therapist
- F. Social worker
Correct Answer: A, B, C, F
Rationale: Total laryngectomy is removal of the entire larynx as well as the hyoid bone, the true vocal cords, the false vocal cords, the epiglottis, the cricoid cartilage, and two to three tracheal rings. The physical therapist is needed for neck exercises. B. The dietitian is needed to ensure adequacy of oral intake. C. The speech therapist is needed for other forms of communication and swallowing. D. The dentist is not routinely consulted when caring for a laryngectomy client. E. An occupational therapist is not routinely consulted when caring for a laryngectomy client. F. The social worker is needed for contact with outside resources to assist the client in ongoing needs.
The nurse is caring for a client diagnosed with acute myeloid leukemia. Which assessment data warrant immediate intervention?
- A. T 99, P 102, R 22, and BP 132/68.
- B. Hyperplasia of the gums.
- C. Weakness and fatigue.
- D. Pain in the left upper quadrant.
Correct Answer: D
Rationale: Left upper quadrant pain (D) suggests splenic rupture, a life-threatening AML complication. Vitals (A) are stable, gum hyperplasia (B) is expected, and fatigue (C) is common.
Which of the following assessment findings should alert the nurse that the elderly client should be evaluated for pernicious anemia?
- A. Clubbing of the nails
- B. Bloody stools
- C. Beefy-red tongue
- D. Enlarged lymph nodes
Correct Answer: C
Rationale: A beefy-red tongue is a classic symptom of pernicious anemia due to vitamin B12 deficiency.