Nokea
The nurse is assessing an African American client diagnosed with sickle cell crisis. Which assessment datum is most pertinent when assessing for cyanosis in clients with dark skin?
- A. Assess the client’s oral mucosa.
- B. Assess the client’s metatarsals.
- C. Assess the client’s capillary refill time.
- D. Assess the sclera of the client’s eyes.
Correct Answer: A
Rationale: Oral mucosa (A) is the best site to assess cyanosis in dark skin, showing dusky color. Metatarsals (B) and sclera (D) are less reliable, and capillary refill (C) assesses perfusion.
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The nurse is discharging a client diagnosed with anemia. Which discharge instruction should the nurse teach?
- A. Take the prescribed iron until it is completely gone.
- B. Monitor pulse and blood pressure at a local pharmacy weekly.
- C. Have a complete blood count checked at the HCP’s office.
- D. Perform isometric exercise three (3) times a week.
Correct Answer: C
Rationale: Multiple Choice CBC checks (C) monitor anemia recovery. Taking iron indefinitely (A) depends on cause, BP/pulse checks (B) are nonspecific, and isometric exercise (D) may strain low oxygen capacity.
The client diagnosed with esophageal cancer is having work-related problems that are interfering with the client's treatment. Which organization should the nurse advise the client to contact for assistance with these issues?
- A. National Cancer Institute
- B. Leukemia Society of America
- C. Corporate Angel Network
- D. Patient Advocate Foundation
Correct Answer: D
Rationale: A. The National Cancer Institute answers questions and has free information about cancer. B. The Leukemia Society of America provides education regarding leukemia. C. The Corporate Angel Network provides free plane transportation for cancer clients going to and from treatment centers. D. The Patient Advocate Foundation provides counseling to resolve job-related problems.
The client who received 50 mL from a unit of whole blood has low back pain. In response to this client’s symptom, which action should be taken by the nurse first?
- A. Reposition the client.
- B. Assess the pain further.
- C. Administer an analgesic.
- D. Stop the blood transfusion.
Correct Answer: D
Rationale: A. Repositioning focuses on treating the client’s back pain and not on the blood transfusion, which could be the cause of the back pain. B. Further assessment should occur after stopping the blood transfusion. C. The client may need an analgesic for pain control, but this should occur after stopping the blood transfusion. D. Low back pain is a symptom of a potentially life-threatening acute hemolytic reaction. The pain is caused from agglutination of RBCs in the kidneys and renal vasoconstriction. Hemolytic reactions occur most often within the first 50 mL of the infusion.
The client is scheduled to have a total hip replacement in two (2) months and has chosen to prepare for autologous transfusions. Which medication would the nurse administer to prepare the client?
- A. Prednisone, a glucocorticoid.
- B. Zithromax, an antibiotic.
- C. Ativan, a tranquilizer.
- D. Epogen, a biologic response modifier.
Correct Answer: D
Rationale: Epogen (D) stimulates RBC production for autologous donation. Prednisone (A), Zithromax (B), and Ativan (C) are unrelated.
A child who has leukemia is to have a bone marrow biopsy performed. How will the child be positioned for this procedure?
- A. On his side with the top knee flexed
- B. Prone
- C. Modified Trendelenburg position
- D. On his back with his head elevated 30 degrees
Correct Answer: B
Rationale: The prone position is used for a bone marrow biopsy from the iliac crest to access the site safely.