Nokea
The nurse is caring for a client who is thought to have pernicious anemia. What signs and symptoms would the nurse expect in this person?
- A. Easy bruising
- B. Beefy-red tongue
- C. Fine red rash on the extremities
- D. Pruritus
Correct Answer: B
Rationale: A beefy-red tongue is a hallmark symptom of pernicious anemia due to vitamin B12 deficiency.
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The nurse assesses the client diagnosed with acute myeloid leukemia. Which finding should be the nurse’s priority for implementing interventions?
- A. Pain from mucositis and oral tissue injury
- B. Weakness and fatigue with slight activity
- C. T 99°F, P 100, R 22, BP 132/64 mm Hg
- D. Ecchymosis and petechiae noted on arms
Correct Answer: A
Rationale: A. Pain control is priority. The altered VS (other than temperature) could be related to pain. B. Weakness and fatigue are due to anemia and also the disease process. It is important to allow rest, but if pain is not controlled the client may not be able to rest. C. The temperature warrants further monitoring because it could indicate a developing infection; the other VS may decrease if pain is controlled. D. Ecchymosis and petechiae are associated with low platelet counts. The nurse should check the laboratory report for the platelet level, but this is an assessment and not an intervention.
The client diagnosed with sickle cell anemia is experiencing a vaso-occlusive sickle cell crisis secondary to an infection. Which medical treatment should the nurse anticipate the HCP ordering for the client?
- A. Administer meperidine (Demerol) intravenously.
- B. Admit the client to a private room and keep in reverse isolation.
- C. Infuse D5W 0.33% NS at 150 mL/hr via pump.
- D. Insert a 22-French Foley catheter with a urimeter.
Correct Answer: C
Rationale: Hydration with IV fluids (C) prevents sickling in vaso-occlusive crisis. Meperidine (A) is avoided (risks seizures), isolation (B) is excessive, and Foley (D) is unnecessary.
The client is diagnosed with polycythemia vera. The nurse would prepare to perform which intervention?
- A. Type and crossmatch for a transfusion.
- B. Assess for petechiae and purpura.
- C. Perform phlebotomy of 500 mL of blood.
- D. Monitor for low hemoglobin and hematocrit.
Correct Answer: C
Rationale: Polycythemia vera requires phlebotomy (C) to reduce blood viscosity. Transfusions (A) worsen hyperviscosity, petechiae (B) are for thrombocytopenia, and Hb/Hct (D) are elevated.
The nurse knows that infectious mononucleosis is caused by which of the following?
- A. Cytomegalovirus
- B. Beta-hemolytic Streptococcus
- C. Epstein-Barr virus
- D. Herpes simplex virus I
Correct Answer: C
Rationale: Infectious mononucleosis is caused by the Epstein-Barr virus.
The client is experiencing pain due to cancer treatment- The client tells the nurse, “Methadone has always worked well for me in the past.” Which effects of methadone should the nurse consider when administering methadone?
- A. Has a long half-life and high level of potency
- B. May cause an increase in BP and confusion
- C. Causes severe allergic reactions and liver failure
- D. Has active metabolites, but it is well tolerated
Correct Answer: A
Rationale: bg