Nokea
The nurse is caring for the client placed on neutropenic precautions. Which interventions should the nurse implement?
- A. Apply pressure for at least 5 minutes to any site that is bleeding.
- B. Prevent anyone from bringing fresh flowers into the client’s room.
- C. Teach the client to avoid eating unwashed fruit and vegetables.
- D. Perform hand hygiene before touching any of the client’s belongings.
- E. Inform the client that fresh water will be delivered every hour.
- F. Stop visitors from entering the room if observed to be coughing.
Correct Answer: B, C, D, F, A.
Rationale: Pressure should be applied to an area that is bleeding when the client has thrombocytopenia, not neutropenia. B. Fresh flowers harbor microorganisms that can cause an infection. C. Unwashed fruits and vegetables have been found to be colonized with various bacteria, particularly gram-negative enteric organisms, as well as pseudomonas and fungi. Recent research indicates that well-washed fresh fruits and vegetables may be eaten. D. Hand hygiene reduces microbial counts on hands and helps to prevent the transmission of microorganisms to the client’s belongings. E. The client should not consume any liquids that have been standing at room temperature for longer than an hour due to risk of microbial colonization. F. Visitors with a transmittable infection place the client at a high risk for becoming infected due to the client’s depressed immune system.
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Laboratory tests are prescribed for the client who has a smooth and reddened tongue and ulcers at the corners of the mouth. Which result would the nurse find if the client has iron-deficiency anemia?
- A. Low hemoglobin and hematocrit
- B. Elevated red blood cells (RBCs)
- C. Prolonged prothrombin time (PT)
- D. Elevated white blood cells (WBCs)
Correct Answer: A
Rationale: A. A smooth, red tongue, ulcers at the corners of the mouth (angular cheilosis), and a low Hgb are signs of iron-deficiency anemia. B. Excess RBCs are associated with polycythemia vera. C. Prolonged PT is seen with clients taking antico-agulants or experiencing a coagulation disorder. D. Elevated WBCs are not associated with iron-deficiency anemia but with an infection. Ulcers, if infected, would elevate the WBCs.
The client’s nephew has just been diagnosed with sickle cell anemia (SCA). The client asks the nurse, 'How did my nephew get this disease?' Which statement would be the best response by the nurse?
- A. Sickle cell anemia is an inherited autosomal recessive disease.'
- B. He was born with it and both his parents were carriers of the disease.'
- C. At this time, the cause of sickle cell anemia is unknown.'
- D. Your sister was exposed to a virus while she was pregnant.'
Correct Answer: A
Rationale: SCA is an autosomal recessive disorder (A), the most precise explanation. Parents as carriers (B) is partial, cause is known (C), and viral exposure (D) is incorrect.
The HCP orders two (2) units of blood to be administered over eight (8) hours each for a client diagnosed with heart failure. Which intervention(s) should the nurse implement?
- A. Call the HCP to question the order because blood must infuse within four (4) hours.
- B. Retrieve the blood from the laboratory and run each unit at an eight (8)-hour rate.
- C. Notify the laboratory to split each unit into half-units and infuse each half for four (4) hours.
- D. Infuse each unit for four (4) hours, the maximum rate for a unit of blood.
Correct Answer: A
Rationale: Blood must infuse within 4 hours to prevent bacterial growth; 8-hour infusion (B) is unsafe, requiring HCP clarification (A). Splitting units (C) is unnecessary, and 4 hours (D) ignores heart failure needs.
The nurse identifies a concept of hematologic regulation for a client diagnosed with leukemia. Which clinical manifestations support the concept?
- A. The client has petechiae on the trunk and extremities.
- B. The client complains of pain and swelling in the joints.
- C. The client has an Hbg of 9.7 and Hct of 32%.
- D. The client complains of a headache and slurred speech.
Correct Answer: A,C
Rationale: Petechiae (A) and low Hb/Hct (C) reflect leukemia’s impact on hematologic regulation (thrombocytopenia, anemia). Joint pain (B) is less common, and headache/slurred speech (D) suggest stroke.
The nurse is caring for the client receiving combination chemotherapy of oxaliplatin, fluorouracil, and leucovorin. The nurse should assess the client for which common side effects of this chemotherapy regimen?
- A. Neurotoxicities and diarrhea
- B. Cardiomyopathy and dysphagia
- C. Renal insufficiency and gastritis
- D. Photophobia and stomatitis
Correct Answer: A
Rationale: A. Neurotoxicity and diarrhea occur frequently in clients receiving the medication regimen of oxaliplatin (Eloxatin), fluorouracil (5-FU), and leucovorin (Wellcovorin). B. Cardiomyopathy and dysphagia are not common side effects of these chemotherapy agents. C. Renal insufficiency and gastritis are not common side effects of these chemotherapy agents. D. Photophobia and stomatitis are not common side effects of these chemotherapy agents.