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The nurse is caring for clients on a medical floor. After the shift report, which client should be assessed first?
- A. The client who is two-thirds of the way through a blood transfusion and has no complaints of dyspnea or hives.
- B. The client diagnosed with leukemia who has a hematocrit of 18% and petechiae covering the body.
- C. The client with peptic ulcer disease who called over the intercom to say that he is vomiting blood.
- D. The client diagnosed with Crohn’s disease who is complaining of perineal discomfort.
Correct Answer: C
Rationale: Vomiting blood (C) indicates active GI bleeding, a life-threatening emergency. Low Hct/petechiae (B) is urgent but stable, transfusion (A) is uneventful, and perineal discomfort (D) is least urgent.
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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 nurse completed teaching the client who had a bone marrow transplant (BMT). Which statement by the client indicates the client misunderstood the expected changes following a BMT?
- A. “I may gain weight from my immunosuppressant medication.”
- B. “Sterility can occur from the chemotherapy and radiation.”
- C. “I may have vision changes from the total body irradiation.”
- D. “Changes to my mouth could include a white, patchy tongue.”
Correct Answer: D
Rationale: A. A common side effect of immunosuppressant medications is weight gain. B. Sterility can occur as a result of chemotherapy and the total body irradiation after BMT. C. Changes in vision are common as a result of the total body irradiation after BMT. D. A white, patchy tongue is a sign of a fungal infection with Candidiasis albicans and would not be an expected change.
Fifteen minutes after the nurse has initiated a transfusion of packed red blood cells, the client becomes restless and complains of itching on the trunk and arms. Which intervention should the nurse implement first?
- A. Collect urine for analysis.
- B. Notify the laboratory of the reaction.
- C. Administer diphenhydramine, an antihistamine.
- D. Stop the transfusion at the hub.
Correct Answer: D
Rationale: Restlessness/itching suggest a transfusion reaction; stopping at the hub (D) prevents further reaction. Urine collection (A), notification (B), and Benadryl (C) follow.
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 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.