Nokea
The nurse is teaching self-care measures to the client hospitalized with HP. Which measures should the nurse plan to include?
- A. “Use dental floss daily after brushing your teeth.”
- B. “Use only an electric razor when you need to shave.”
- C. “Remove throw rugs in your home and avoid clutter.”
- D. “Increase fiber in your diet and drink plenty of liquids.”
- E. “Keep appointments for monthly platelet transfusions.”
Correct Answer: B, C, D
Rationale: Dental floss can traumatize the gums and increase the risk for bleeding. B. Because the client is at risk for bleeding due to low platelet counts, measures to decrease the risk of bleeding should be implemented, such as using an electric razor. C. Throw rugs and clutter increase the risk for falls with subsequent bleeding. D. Fiber and fluids help prevent constipation. Constipation can lead to hemorrhoids and increase the risk for bleeding. E. Platelet transfusions are usually avoided because the person’s antiplatelet antibodies bind with the transfused platelets, causing them to be destroyed.
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The nurse is caring for the following clients. Which client should the nurse assess first?
- A. The client whose partial thromboplastin time (PTT) is 38 seconds.
- B. The client whose hemoglobin is 14 g/dL and hematocrit is 45%.
- C. The client whose platelet count is 75,000 per cubic millimeter of blood.
- D. The client whose red blood cell count is 4.8 x 106/mm3.
Correct Answer: C
Rationale: Platelets 75,000 (C) indicate thrombocytopenia, risking bleeding, a priority. PTT 38 (A) is therapeutic, Hb/Hct (B) are normal, and RBC 4.8 (D) is normal.
The nurse is caring for multiple 25-year-old female clients. The nurse should plan to consult the HCP about a referral for genetic counseling and family planning for which clients?
- A. Client diagnosed with thalassemia major
- B. Client diagnosed with sickle cell anemia
- C. Client diagnosed with hemophilia A
- D. Client diagnosed with autoimmune hemolytic anemia
- E. Client diagnosed with hemophilia B
Correct Answer: A, B, C, E
Rationale: Thalassemia is a hereditary disorder; the client could benefit from a referral for genetic counseling. B. Sickle cell anemia is a hereditary disorder; the client could benefit from a referral for genetic counseling. C. Hemophilia A is a hereditary disorder; the client could benefit from a referral for genetic counseling. D. Autoimmune hemolytic anemia is an acquired hemolytic anemia. E. Hemophilia B is a hereditary disorder; the client could benefit from a referral for genetic counseling.
A child who has leukemia is to have a bone marrow biopsy performed. How will the child be positioned for this procedure?
- A. On his side with the top knee flexed
- B. Prone
- C. Modified Trendelenburg position
- D. On his back with his head elevated 30 degrees
Correct Answer: B
Rationale: The prone position is used for a bone marrow biopsy from the iliac crest to access the site safely.
The client asks the nurse to look at a lesion on the client’s body. Which characteristics should prompt the nurse to consider that the client may have a basal cell carcinoma (BCC)?
- A. Nodular in appearance, depression in the center, and has a “pearly” characteristic
- B. Irregular color, surface, and border, less than one centimeter, and appears eroded
- C. Dry, hyperkeratotic scaly-like papule and has the appearance similar to a wart
- D. Vesiculopustular lesion with a thick, honey-colored crust and pruritic in nature
Correct Answer: A
Rationale: BCC is nodular and ulcerative. Clinical manifestations include small, slowly enlarging papule; borders are translucent or “pearly” with overlying telangiectasia; erosion, ulceration, and depression of center. B. Clinical manifestations of malignant melanoma (not BCC) include irregular color, surface, and border; variegation of color including red, white, blue, black, gray, brown; flat or elevated; eroded or ulcerated. C. Actinic keratosis (not BCC) is characterized by being horny and “wartlike.” D. Impetigo is characterized by thick, honey-colored crusts and is treated with antibiotics and topical treatment.
Cup of decatfeinated coffee for breakfast and lunch, 90 mL apple juice, 120 mL ice cream, 180 mL chicken broth, mashed potatoes, few bites of chicken, bowl of carrots, 240 mL milk, and 90 mL gelatin. How many milliliters should the nurse record for the client’s 8-hour fluid intake? __________ L (Record your answer as a whole number.)
Correct Answer: 2200
Rationale: First convert to milliliters: l L = 1000 mL;
1 oz = 30 mL
Next add the values for fluids: 1000 + 240 + 240 + 90 + 120 + 180 + 240 + 90 = 2200