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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A 1-year-old is admitted to the hospital with sickle cell anemia in crisis. Upon admission, which therapy will assume priority?
- A. Fluid administration
- B. Exchange transfusion
- C. Anticoagulant
- D. IM administration of iron and folic acid
Correct Answer: A
Rationale: Fluid administration is the priority in sickle cell crisis to prevent dehydration and reduce blood viscosity, which can worsen sickling.
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 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.
Which interrelated psychological concept is priority for the nurse caring for a client diagnosed with leukemia?
- A. Comfort.
- B. Stress.
- C. Grieving.
- D. Coping.
Correct Answer: C
Rationale: Leukemia’s life-threatening nature makes grieving (C) a priority, addressing loss of health. Comfort (A), stress (B), and coping (D) are secondary.
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.