Nokea
The nurse is assessing a client diagnosed with acute myeloid leukemia. Which assessment data support this diagnosis?
- A. Fever and infections.
- B. Nausea and vomiting.
- C. Excessive energy and high platelet counts.
- D. Cervical lymph node enlargement and positive acid-fast bacillus.
Correct Answer: A
Rationale: AML causes neutropenia, leading to fever/infections (A). Nausea (B) is nonspecific, high platelets/energy (C) are incorrect (AML causes thrombocytopenia/fatigue), and acid-fast bacillus (D) indicates TB, not AML.
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The client is admitted to the emergency department after a motor-vehicle accident. The nurse notes profuse bleeding from a right-sided abdominal injury. Which intervention should the nurse implement first?
- A. Type and crossmatch for red blood cells immediately (STAT).
- B. Initiate an IV with an 18-gauge needle and hang normal saline.
- C. Have the client sign a consent for an exploratory laparotomy.
- D. Notify the significant other of the client’s admission.
Correct Answer: B
Rationale: Profuse bleeding requires immediate IV access with 18-gauge and NS (B) to stabilize hemodynamics. Crossmatch (A), consent (C), and notification (D) follow.
The client diagnosed with sickle cell anemia asks the nurse, 'Why should I take those shots? I hate shots.' Which statement by the nurse is the best response?
- A. These vaccines promote health in clients with chronic illnesses.'
- B. You are susceptible to infections. These shots may help prevent a crisis.'
- C. The vaccines will help your blood from sickling secondary to viruses.'
- D. The doctor wanted to make sure that I discussed the vaccines with you.'
Correct Answer: B
Rationale: Flu/pneumonia vaccines (B) reduce infection risk, a common SCA crisis trigger. General health (A) is vague, sickling (C) is indirect, and HCP mention (D) avoids explanation.
Laboratory tests are prescribed for the client who has a smooth and reddened tongue and ulcers at the corners of the mouth. Which result would the nurse find if the client has iron-deficiency anemia?
- A. Low hemoglobin and hematocrit
- B. Elevated red blood cells (RBCs)
- C. Prolonged prothrombin time (PT)
- D. Elevated white blood cells (WBCs)
Correct Answer: A
Rationale: A. A smooth, red tongue, ulcers at the corners of the mouth (angular cheilosis), and a low Hgb are signs of iron-deficiency anemia. B. Excess RBCs are associated with polycythemia vera. C. Prolonged PT is seen with clients taking antico-agulants or experiencing a coagulation disorder. D. Elevated WBCs are not associated with iron-deficiency anemia but with an infection. Ulcers, if infected, would elevate the WBCs.
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.
The client has a blood type of B negative. The client’s family asks if they can donate blood for the client. The nurse informs the family that they would need to be of which blood type to be considered for a directed donation of RBCs for this client?
- A. Type A positive
- B. Type B positive
- C. Type B negative
- D. Type O positive
- E. Type O negative
- F. Type AB positive
Correct Answer: C, E, A
Rationale: Blood type A positive has the D antigen on the RBC, making it incompatible with blood type B negative. B. Blood type B positive has the D antigen on the RBC, making it incompatible with blood type B negative. C. The client with B negative blood type has B antigen on the RBC and does not have an Rh (or D) antigen on the cell. Because the client can receive RBCs of the same blood type, a person with type B negative blood could be considered for a directed donation. D. Blood type O positive has the D antigen, making it incompatible with blood type B negative. E. Type O negative has no antigens on the RBC so a directed donation from a person with type O negative blood could also be considered. F. Blood type AB positive has the D antigen on the RBC, making it incompatible with blood type B negative.