Nokea
The nurse is admitting a patient with type A hemophilia who has severe pain and swelling in the right knee. Which of the following actions should the nurse implement initially?
- A. Immobilize the knee
- B. Apply heat to the joint
- C. Assist the patient with light weight bearing
- D. Perform passive range of motion to the knee
Correct Answer: A
Rationale: The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.
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Which of the following nursing interventions should be included in the care plan for a patient with immune thrombocytopenic purpura (ITP)?
- A. Assign the patient to a private room.
- B. Avoid intramuscular (IM) injections.
- C. Use rinses rather than a toothbrush for oral care.
- D. Restrict activity to passive and active range of motion.
Correct Answer: B
Rationale: IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.
The nurse is caring for a patient with polycythemia vera. Which of the following actions should the nurse implement during treatment?
- A. Place the patient on bed rest.
- B. Administer iron supplements.
- C. Avoid use of aspirin products.
- D. Monitor fluid intake and output.
Correct Answer: D
Rationale: Monitoring hydration status is essential in polycythemia vera to prevent thrombosis due to increased blood viscosity. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis (DVT). Iron is contraindicated in patients with polycythemia vera.
Which of the following menu choices indicate that the patient understands the nurse's teaching about best dietary choices for iron-deficiency anemia?
- A. Omelet and whole wheat toast
- B. Cantaloupe and cottage cheese
- C. Strawberry and banana fruit plate
- D. Cornmeal muffin and orange juice
Correct Answer: A
Rationale: Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies, but are not the best choice for a patient with iron-deficiency anemia.
After receiving change-of-shift report for the following four patients with neutropenia, which patient should the nurse assess first?
- A. 66-year-old who has white pharyngeal lesions
- B. 35-year-old who has a fever of 38.2°C (100.8°F)
- C. 36-year-old who has frequent explosive diarrhea
- D. 23-year old who is complaining of severe fatigue
Correct Answer: B
Rationale: Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problems.
The nurse is planning discharge teaching for a patient who was admitted with neutropenia. Which of the following instructions should the nurse include?
- A. Limit fluids to 2-3 litres a day.
- B. Include eggs and fish in the diet.
- C. Avoid exposure to crowds as much as possible.
- D. Drink only one or two caffeinated beverages daily.
Correct Answer: C
Rationale: Exposure to crowds increases the risk of infection in neutropenic patients. Limiting fluids or caffeinated beverages is not necessary, and eggs and fish are acceptable in the diet unless otherwise contraindicated.