Nokea
The nurse is admitting a client with a diagnosis of rule-out Hodgkin's lymphoma. Which assessment data support this diagnosis?
- A. Night sweats and fever without 'chills.'
- B. Edematous lymph nodes in the groin.
- C. Malaise and complaints of an upset stomach.
- D. Pain in the neck area after a fatty meal.
Correct Answer: A
Rationale: Night sweats and fever (A) are classic Hodgkin’s B symptoms. Edematous nodes (B) are not typical (firm, non-tender), malaise/stomach (C) is nonspecific, and neck pain (D) suggests gallbladder issues.
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The nurse writes a nursing problem of 'altered nutrition' for a client diagnosed with leukemia who has received a treatment regimen of chemotherapy and radiation. Which nursing intervention should be implemented?
- A. Administer an antidiarrheal medication prior to meals.
- B. Monitor the client's serum albumin levels.
- C. Assess for signs and symptoms of infection.
- D. Provide skin care to irradiated areas.
Correct Answer: B
Rationale: Altered nutrition requires monitoring serum albumin (B) to assess protein status. Antidiarrheals (A) are symptom-specific, infection (C) is unrelated, and skin care (D) addresses radiation effects.
A Schilling test has been ordered for a client suspected of having pernicious anemia. What is the nurse's primary responsibility in relation to this test?
- A. Collect the blood samples
- B. Collect a 24-hour urine sample
- C. Assist the client to x-ray
- D. Administer an enema
Correct Answer: B
Rationale: The Schilling test involves administering radioactive vitamin B12 orally and collecting a 24-hour urine sample to assess absorption, indicating the nurse's primary responsibility.
The nurse is working in a blood bank facility procuring units of blood from donors. Which client would not be a candidate to donate blood?
- A. The client who had wisdom teeth removed a week ago.
- B. The nursing student who received a measles immunization two (2) months ago.
- C. The mother with a six (6)-week-old newborn.
- D. The client who developed an allergy to aspirin in childhood.
Correct Answer: C
Rationale: Recent childbirth (C) (within 6 months) disqualifies blood donation due to anemia risk. Wisdom teeth (A), immunization (B), and aspirin allergy (D) are not contraindications.
The client diagnosed with anemia begins to complain of dyspnea when ambulating in the hall. Which intervention should the nurse implement first?
- A. Apply oxygen via nasal cannula.
- B. Get a wheelchair for the client.
- C. Assess the client’s lung fields.
- D. Assist the client when ambulating in the hall.
Correct Answer: B
Rationale: Dyspnea in anemia suggests low oxygen-carrying capacity; a wheelchair (B) prevents exertion while further assessment occurs. Oxygen (A), lung assessment (C), and assistance (D) follow.
The nurse working in the bloodmobile is screening clients to determine if they qualify for blood donation of whole blood. Besides asking for identification and age, which questions should the nurse ask during the screening interview?
- A. “If you have a tattoo, on what date did you receive the tattoo?”
- B. “Have you had any close contact with anyone with HIV or hepatitis?”
- C. “If you smoke, when was the last time you smoked tobacco products?”
- D. “When were you last immunized for rubella, mumps, or varicella?”
- E. “Did you receive blood products anywhere outside of the United States?”
Correct Answer: A, B, D, E
Rationale: Persons ineligible to donate blood include those with a history of a recent tattoo. B. Persons ineligible to donate blood include those who’ve had close contact with a person with HIV or hepatitis. C. Persons who smoke tobacco products may donate blood unless they have a recent history of asthma. D. Persons ineligible to donate blood include those immunized for rubella, mumps, or varicella within the last month. E. Persons ineligible to donate blood include those receiving transfusions in the United Kingdom, Gibraltar, or the Falkland Islands because of the increased likelihood of transmitting Creutzfeldt-Jakob disease.