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The nurse is caring for clients on an oncology unit. Which neutropenia precautions should be implemented?
- A. Hold all venipuncture sites for at least five (5) minutes.
- B. Limit fresh fruits and flowers.
- C. Place all clients in reverse isolation.
- D. Have the clients use a soft-bristle toothbrush.
Correct Answer: B
Rationale: Neutropenia increases infection risk; limiting fresh fruits/flowers (B) reduces microbial exposure. Holding venipuncture (A) prevents bleeding, reverse isolation (C) is excessive, and soft toothbrushes (D) prevent gum trauma but are secondary.
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The client diagnosed with anemia has an Hb of 6.1 g/dL. Which complication should the nurse assess for?
- A. Decreased pulmonary functioning.
- B. Impaired muscle functioning.
- C. Congestive heart failure.
- D. Altered gastric secretions.
Correct Answer: C
Rationale: Severe anemia (Hb 6.1) reduces oxygen delivery, straining the heart and risking CHF (C). Pulmonary (A), muscle (B), and gastric (D) issues are less direct.
The client is diagnosed with non-Hodgkin’s lymphoma. Which nursing concept should the nurse identify as priority?
- A. Immunity.
- B. Grieving.
- C. Perfusion.
- D. Clotting.
Correct Answer: A
Rationale: NHL impairs immunity (A) via lymph node dysfunction, increasing infection risk, a priority. Grieving (B), perfusion (C), and clotting (D) are secondary.
The nurse explains “watchful waiting” (ongoing visits to a physician for observation of signs and symptoms without treatment) to the client with prostate cancer. Which client is a candidate for “watchful waiting”?
- A. 50-year-old with prostate cancer that has metastasized to the bone
- B. 75-year-old expected to live 5 years and has low-grade disease
- C. 45-year-old who has extension of the tumor outside of the prostate
- D. 59-year-old who is asymptomatic with an elevated prostate-specific antigen
Correct Answer: B
Rationale: A. The client with prostate cancer that has metastasized to the bone generally requires aggressive therapy. B. The client is a candidate for “watchful waiting” when older than age 70 with a life expectancy of less than 10 years and with low-grade disease. C. The client with extension of the tumor outside of the prostate generally requires aggressive therapy. D. The client who is asymptomatic with an elevated prostate-specific antigen generally requires aggressive therapy.
The charge nurse in the intensive care unit is making client assignments. Which client should the charge nurse assign to the graduate nurse who has just finished the three (3)-month orientation?
- A. The client with an abdominal peritoneal resection who has a colostomy.
- B. The client diagnosed with pneumonia who has acute respiratory distress syndrome.
- C. The client with a head injury developing disseminated intravascular coagulation.
- D. The client admitted with a gunshot wound who has an H&H of 7 and 22.
Correct Answer: A
Rationale: Colostomy care (A) is stable and suitable for a new graduate. ARDS (B), DIC (C), and severe anemia (D) are critical, requiring experienced care.
Which medication is contraindicated for a client diagnosed with leukemia?
- A. Bactrim, a sulfa antibiotic.
- B. Morphine, a narcotic analgesic.
- C. Epogen, a biologic response modifier.
- D. Gleevec, a genetic blocking agent.
Correct Answer: C
Rationale: Epogen (C) stimulates RBC production, risky in leukemia due to blast proliferation. Bactrim (A) treats infections, morphine (B) manages pain, and Gleevec (D) targets CML.