Nokea
The nurse is admitting a 24-year-old African American female client with a diagnosis of rule-out anemia. The client has a history of gastric bypass surgery for obesity four (4) years ago. Current assessment findings include height 5’5”; weight 75 kg; P 110, R 27, and BP 104/66; pale mucous membranes and dyspnea on exertion. Which type of anemia would the nurse suspect the client has developed?
- A. Vitamin B12 deficiency.
- B. Folic acid deficiency.
- C. Iron deficiency.
- D. Sickle cell anemia.
Correct Answer: A
Rationale: Gastric bypass impairs B12 absorption, causing B12 deficiency anemia (A) with pale membranes, tachycardia, and dyspnea. Folic acid (B) is less likely, iron (C) is possible but secondary, and sickle cell (D) is genetic.
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The nurse is caring for clients on an oncology unit. Which neutropenia precautions should be implemented?
- A. Hold all venipuncture sites for at least five (5) minutes.
- B. Limit fresh fruits and flowers.
- C. Place all clients in reverse isolation.
- D. Have the clients use a soft-bristle toothbrush.
Correct Answer: B
Rationale: Neutropenia increases infection risk; limiting fresh fruits/flowers (B) reduces microbial exposure. Holding venipuncture (A) prevents bleeding, reverse isolation (C) is excessive, and soft toothbrushes (D) prevent gum trauma but are secondary.
Following morning shift report, the nurse identifies care needs for four clients. Which client should be the nurse’s priority?
- A. The client with lung cancer who is to receive ondansetron 8 mg IV 30 minutes prior to chemotherapy
- B. The client with an absolute neutrophil count of 98/mm3 who needs to be placed on neutropenic precautions
- C. The client who is stable but has breast cancer and is scheduled for external beam radiation in 15 minutes
- D. The client with stomatitis from radiation for tonsillar cancer who is to receive a gastrostomy tube feeding
Correct Answer: B
Rationale: A. No time is noted for the administration of ondansetron (Zofran) prior to chemotherapy treatment; this client is not the nurse’s priority. B. The client with neutropenia should be the nurse’s priority. If seen first, microorganisms from other clients would be less likely to be transmitted to the client. This client is at risk for infection and severe sepsis because the absolute neutrophil count is less than 1001mm3 (normal = 1500 to 8000/mm3). C. This client is stable; another person can take this client to radiation therapy, and the nurse’s assessment can wait until the client returns. D. The tube feeding can be initiated after the needs of the most critical client are met.
The client diagnosed with non-Hodgkin's lymphoma is scheduled for a lymphangiogram. Which information should the nurse teach?
- A. The scan will identify any malignancy in the vascular system.
- B. Radiopaque dye will be injected between the toes.
- C. The test will be done similar to a cardiac angiogram.
- D. The test will be completed in about five (5) minutes.
Correct Answer: B
Rationale: Lymphangiogram involves dye injection between toes (B) to visualize lymphatics. It’s not vascular (A), unlike cardiac angiogram (C), and takes longer than 5 minutes (D).
The client diagnosed with anemia has an Hb of 6.1 g/dL. Which complication should the nurse assess for?
- A. Decreased pulmonary functioning.
- B. Impaired muscle functioning.
- C. Congestive heart failure.
- D. Altered gastric secretions.
Correct Answer: C
Rationale: Severe anemia (Hb 6.1) reduces oxygen delivery, straining the heart and risking CHF (C). Pulmonary (A), muscle (B), and gastric (D) issues are less direct.
Which medication is contraindicated for a client diagnosed with leukemia?
- A. Bactrim, a sulfa antibiotic.
- B. Morphine, a narcotic analgesic.
- C. Epogen, a biologic response modifier.
- D. Gleevec, a genetic blocking agent.
Correct Answer: C
Rationale: Epogen (C) stimulates RBC production, risky in leukemia due to blast proliferation. Bactrim (A) treats infections, morphine (B) manages pain, and Gleevec (D) targets CML.