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The nurse is caring for a patient with a sickle cell crisis. While caring for the patient during the crisis, which of the following actions is priority?
- A. Limit the patient's intake of oral and IV fluids.
- B. Evaluate the effectiveness of opioid analgesics.
- C. Encourage the patient to ambulate as much as tolerated.
- D. Teach the patient about high-protein, high-calorie foods.
Correct Answer: B
Rationale: Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.
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The nurse is admitting a patient with hemolytic anemia and notes jaundice of the sclerae. Which of the following laboratory results should the nurse assess?
- A. Schilling test
- B. Bilirubin level
- C. Stool occult blood test
- D. Gastric analysis testing
Correct Answer: B
Rationale: Jaundice is caused by the elevation of bilirubin level associated with red blood cell (RBC) hemolysis. The other tests would not be helpful in monitoring or treating hemolytic anemia.
The nurse is caring for a patient with idiopathic aplastic anemia. Which of the following collaborative problems should the nurse include when developing the care plan?
- A. Potential complication: seizures
- B. Potential complication: infection
- C. Potential complication: neurogenic shock
- D. Potential complication: pulmonary edema
Correct Answer: B
Rationale: Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema.
Which of the following nursing actions should the nurse include in the plan of care for a patient admitted with multiple myeloma?
- A. Monitor fluid intake and output.
- B. Administer calcium supplements.
- C. Assess lymph nodes for enlargement.
- D. Limit weight bearing and ambulation.
Correct Answer: A
Rationale: A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient's calcium level and are not used.
A routine complete blood count indicates that a patient may have myelodysplastic syndrome. At this time, which of the following information should the nurse include in the teaching plan?
- A. Packed red blood cells (PRBCs) transfusion
- B. Bone marrow biopsy
- C. Filgrastim administration
- D. Erythropoietin administration
Correct Answer: B
Rationale: Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.
Which of the following actions should the nurse include in the care plan for a hospitalized patient who is neutropenic?
- A. Avoid any IM or subcutaneous injections.
- B. Check the oral temperature every 4 hours.
- C. Omit all fruits or vegetables from the diet.
- D. Place a 'No Visitors' sign on the patient door.
Correct Answer: B
Rationale: The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim. The number of visitors may be limited and visitors with communicable diseases should be avoided, but a 'no visitors' policy is not needed.