Nokea
The nurse is assessing a client with chronic myeloid leukemia (CML). The nurse should assess the client for:
- A. Lymphadenopathy.
- B. Hyperplasia of the gums.
- C. Bone marrow expansion.
- D. Shortness of breath.
Correct Answer: D
Rationale: CML causes an overproduction of white blood cells, leading to symptoms like fatigue, splen enlarge, and shortness of breath due to anemia or hyperviscosity. Shortness of breath is a common finding to assess. Lymphadenopathy, gum hyperplasia, and marrow expansion are less typical.
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The nurse is developing a care plan for a client with leukemia. The plan should include which of the following? Select all that apply.
- A. Monitor temperature and report elevation.
- B. Recognize signs and symptoms of infection.
- C. Avoid crowds.
- D. Maintain integrity of skin and mucous membranes.
- E. Take a baby aspirin each day.
Correct Answer: A,B,C,D
Rationale: Leukemia increases infection risk due to impaired immune function. Monitoring temperature, recognizing infection signs, avoiding crowds, and maintaining skin/mucous membrane integrity are critical to prevent and detect infections. Baby aspirin is not indicated and may increase bleeding risk in leukemia.
After an intravenous pyelogram (IVP), the nurse should not include incorporating which of the following measures into the client's plan of care?
- A. Maintaining bed rest.
- B. Encouraging adequate fluid intake.
- C. Assessing for hematuria.
- D. Administering a laxative.
Correct Answer: D
Rationale: Administering a laxative is unnecessary post-IVP, as it does not aid recovery or contrast excretion, unlike fluid intake or hematuria assessment.
Pseudoephedrine (Sudafed) has been ordered as a nasal decongestant. Which of the following is a possible adverse effect of this drug?
- A. Constipation.
- B. Bradycardia.
- C. Diplopia.
- D. Restlessness.
Correct Answer: D
Rationale: Pseudoephedrine is a sympathomimetic that can cause central nervous system stimulation, leading to restlessness. Constipation, bradycardia, and diplopia are not common adverse effects of this medication.
A client has developed a hospital-acquired pneumonia. When preparing to administer cephalexin (Keflex) 500 mg, the nurse notices that the pharmacy sent cefazolin (Kefzol). What should the nurse do? Select all that apply.
- A. Administer the cefazolin (Kefzol).
- B. Verify the medication order as written by the physician.
- C. Contact the pharmacy and speak to a pharmacist.
- D. Request that cephalexin (Keflex) be sent promptly.
- E. Return the cefazolin (Kefzol) to the pharmacy.
Correct Answer: B,C,D,E
Rationale: The nurse should verify the order (B), contact the pharmacy (C), request the correct medication (D), and return the incorrect drug (E). Administering cefazolin (A) risks a medication error.
The client with type 1 diabetes mellitus is taught to take NPH insulin at 5 p.m. each day. The client should be instructed that the greatest risk of hypoglycemia will occur at about what time?
- A. 11 a.m., shortly before lunch.
- B. 1 p.m., shortly after lunch.
- C. 6 p.m., shortly after dinner.
- D. 1 a.m., while sleeping.
Correct Answer: D
Rationale: NPH insulin peaks 4–12 hours after administration (around 9 p.m. to 5 a.m.), with the greatest hypoglycemia risk overnight, such as at 1 a.m.