Nokea
The nurse identifies a concept of hematologic regulation for a client diagnosed with leukemia. Which clinical manifestations support the concept?
- A. The client has petechiae on the trunk and extremities.
- B. The client complains of pain and swelling in the joints.
- C. The client has an Hbg of 9.7 and Hct of 32%.
- D. The client complains of a headache and slurred speech.
Correct Answer: A,C
Rationale: Petechiae (A) and low Hb/Hct (C) reflect leukemia’s impact on hematologic regulation (thrombocytopenia, anemia). Joint pain (B) is less common, and headache/slurred speech (D) suggest stroke.
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When assessing the client who is recovering from a radical hysterectomy with vulvectomy, the nurse notes lymphedema of the lower extremities. Which intervention should be implemented by the nurse?
- A. Elevate the head of the client’s bed to 45 degrees.
- B. Increase the client’s intake of fluids high in sodium.
- C. Encourage the client to exercise the lower extremities.
- D. Apply splints to both of the client’s lower extremities.
Correct Answer: C
Rationale: A. Elevating the head of the bed to a 45-degree angle may increase lymphedema of the lower extremities. B. Intake of fluids high in sodium will cause fluid retention. C. Leg exercises will improve drainage when lymphedema is present. D. Lower-extremity splints can cause skin breakdown of edematous tissue.
The nurse is administering a transfusion of packed red blood cells to a client. Which interventions should the nurse implement? List in order of performance.
- A. Start the transfusion slowly.
- B. Have the client sign a permit.
- C. Assess the IV site for size and patency.
- D. Check the blood with another nurse at the bedside.
- E. Obtain the blood from the laboratory.
Correct Answer: E,C,B,D,A
Rationale: 1. Obtain blood (E): Retrieve from lab. 2. Assess IV site (C): Ensure 18-gauge patency. 3. Sign permit (B): Obtain consent. 4. Check blood (D): Verify with another nurse. 5. Start slowly (A): Infuse at 10–15 mL/hr initially.
Which is the primary goal of care for a client diagnosed with sickle cell anemia?
- A. The client will call the HCP if feeling ill.
- B. The client will be compliant with medical regimen.
- C. The client will live as normal a life as possible.
- D. The client will verbalize understanding of treatments.
Correct Answer: C
Rationale: The primary goal for SCA is to live normally (C), managing crises. Calling HCP (A), compliance (B), and understanding (D) are secondary.
Which client would be most at risk for developing disseminated intravascular coagulation (DIC)?
- A. A 35-year-old pregnant client with placenta previa.
- B. A 42-year-old client with a pulmonary embolus.
- C. A 60-year-old client receiving hemodialysis three (3) days a week.
- D. A 78-year-old client diagnosed with septicemia.
Correct Answer: D
Rationale: Septicemia (D) is a major DIC trigger due to systemic inflammation/coagulation. Placenta previa (A), PE (B), and dialysis (C) are lower risk.
The nurse is caring for the client who had a left modified radical mastectomy (a total mastectomy with axillary node dissection and removal of the lining over the pectoralis major muscle). Which action by the nurse is appropriate?
- A. Have the client elevate the left arm above the head
- B. Ensure that IV access sites are only on the right side
- C. Have the client view the incision site as soon as possible
- D. Initiate left arm strengthening within 24 hours of surgery
Correct Answer: B
Rationale: A. The arm on the operative side should be elevated on a pillow, but not above the head. B. All IV access sites should be located on the nonoperative side to prevent circulatory impairment. C. Having the client look at the incision should be at the client’s readiness, not as soon as possible. D. Only ROM to the lower arm should be carried out for the first few days after surgery, with exercises and ROM to the shoulder after the drains are removed.