Nokea
The nurse is assessing a patient with chronic lung disease. Which finding indicates long-term hypoxia?
- A. Pallor
- B. Dyspnea
- C. Clubbed fingertips
- D. Pulmonary crackles
Correct Answer: C
Rationale: The correct answer is C: Clubbed fingertips. Clubbing is a sign of prolonged hypoxia due to chronic lung disease. It is characterized by enlargement and rounding of the fingertips. This occurs as a result of chronic hypoxia causing tissue changes in the fingers. Pallor (A) is a pale skin color often indicating decreased blood flow. Dyspnea (B) is difficulty breathing and can be an acute symptom of hypoxia. Pulmonary crackles (D) are abnormal lung sounds indicating fluid accumulation and are not specific to long-term hypoxia.
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A nurse is caring for a client who recently started alteplase therapy. The nurse should monitor the client for which of the following adverse effects?
- A. Bronchodilation
- B. Headache
- C. Edema
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Headache. Alteplase is a thrombolytic medication that can increase the risk of bleeding, including intracranial bleeding, leading to headaches. Monitoring for headaches is crucial to detect any signs of bleeding. Bronchodilation (A) is not a common adverse effect of alteplase. Edema (C) and hypertension (D) are also not typically associated with alteplase therapy. Monitoring for headache is essential for early detection of potentially life-threatening complications.
A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure?
- A. Elevate the head of the bed to 45 degrees.
- B. Apply a sterile 2-inch gauze dressing to the site.
- C. Use a half-inch sterile gauze to pack the wound.
- D. Have the patient lie on the left side for 1 hour.
Correct Answer: D
Rationale: The correct answer is D: Have the patient lie on the left side for 1 hour. This position helps prevent bleeding by applying pressure to the site. Elevating the head of the bed (A) is not necessary for this procedure. Applying a 2-inch gauze dressing (B) may disrupt the site and increase the risk of bleeding. Using half-inch sterile gauze to pack the wound (C) is not recommended for bone marrow aspiration sites as it can lead to infection.
A nurse is monitoring a client who is undergoing anticoagulant therapy with heparin. Which of the following findings should the nurse identify as a possible indication of hemorrhage?
- A. Rapid pulse
- B. Yellowing of the sclera
- C. Elevated blood pressure
- D. Pale-colored stools
Correct Answer: A
Rationale: The correct answer is A: Rapid pulse. Hemorrhage is a potential complication of anticoagulant therapy with heparin due to the increased risk of bleeding. A rapid pulse can indicate hypovolemia from blood loss, a common sign of hemorrhage. Yellowing of the sclera (choice B) is a sign of jaundice, not directly related to hemorrhage. Elevated blood pressure (choice C) is not typically associated with hemorrhage. Pale-colored stools (choice D) can be indicative of liver or gallbladder issues, but not specifically hemorrhage. Overall, a rapid pulse is the most relevant finding to indicate possible hemorrhage in a client on heparin therapy.
Which of the following is a cause of secondary neutropaenia in adults?
- A. Congenital
- B. Anti-hypertensive drugs
- C. Part of general pancytopaenia
- D. Familial
Correct Answer: C
Rationale: Rationale: Secondary neutropenia in adults is often a part of general pancytopenia, which involves a decrease in all three blood cell types. This can be caused by factors such as bone marrow suppression from chemotherapy, radiation therapy, or certain medications. Neutropenia is not typically congenital or familial in adults, and anti-hypertensive drugs are not commonly known to directly cause secondary neutropenia. Therefore, the correct answer is C as it aligns with the common etiology of secondary neutropenia in adults.
A 36-year-old woman presented with weakness, lassitude, and feeling easily tired. Her bone marrow aspirate showed 15% myeloblasts and reduced erythropoiesis. The most likely cause is
- A. Acute myeloid leukemia
- B. Acute lymphoid leukemia
- C. Myelofibrosis
- D. Myelodysplastic syndrome
Correct Answer: D
Rationale: The correct answer is D: Myelodysplastic syndrome. Given the patient's age, symptoms, and bone marrow findings of myeloblasts with reduced erythropoiesis, it aligns with the characteristics of myelodysplastic syndrome. This condition involves abnormal blood cell production leading to cytopenias and an increased risk of progression to acute myeloid leukemia. Acute myeloid leukemia (Choice A) typically presents with higher blast percentages and more aggressive symptoms. Acute lymphoid leukemia (Choice B) is less likely due to the presence of myeloblasts in the bone marrow. Myelofibrosis (Choice C) is characterized by fibrosis in the bone marrow, which is not indicated in this case.