Nokea
The nurse is transcribing the HCP’s order for an iron supplement on the MAR. At which time should the nurse schedule the daily dose?
- A. 900
- B. 1000
- C. 1200
- D. 1630
Correct Answer: A
Rationale: Iron supplements are best taken in the morning (0900, A) with food to reduce GI upset and enhance absorption. Later times (B, C, D) are less optimal.
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The client diagnosed with atrial fibrillation is admitted with warfarin (Coumadin) toxicity. Which HCP order would the nurse anticipate?
- A. Protamine sulfate, an anticoagulant antidote.
- B. Heparin sodium, an anticoagulant.
- C. Lovenox, a low molecular weight anticoagulant.
- D. Vitamin K, an anticoagulant agonist.
Correct Answer: D
Rationale: Warfarin toxicity causes bleeding; vitamin K (D) reverses it. Protamine (A) reverses heparin, heparin/Lovenox (B, C) worsen bleeding.
The client diagnosed with leukemia is scheduled for bone marrow transplantation. Which interventions should be implemented to prepare the client for this procedure? Select all that apply.
- A. Administer high-dose chemotherapy.
- B. Teach the client about autologous transfusions.
- C. Have the family members' HLA typed.
- D. Monitor the complete blood cell count daily.
- E. Provide central line care per protocol.
Correct Answer: A,C,D,E
Rationale: High-dose chemotherapy (A) ablates marrow, HLA typing (C) identifies donors, CBC monitoring (D) tracks counts, and central line care (E) prevents infection. Autologous transfusions (B) are irrelevant (donor marrow used).
A college student who is diagnosed as having infectious mononucleosis asks how the disease is spread. The nurse's response is based on the knowledge that the usual mode of transmission is through:
- A. skin.
- B. genital contact.
- C. contaminated water.
- D. intimate oral contact.
Correct Answer: D
Rationale: Infectious mononucleosis, known as the 'kissing disease,' is spread through intimate oral contact, such as kissing or sharing utensils.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on an oncology floor. Which nursing task would be delegated to the UAP?
- A. Assess the urine output on a client who has had a blood transfusion reaction.
- B. Take the first 15 minutes of vital signs on a client receiving a unit of PRBCs.
- C. Auscultate the lung sounds of a client prior to a transfusion.
- D. Assist a client who received 10 units of platelets in brushing the teeth.
Correct Answer: B
Rationale: Taking initial vital signs (B) during transfusion is within UAP scope. Assessing urine (A), lung sounds (C), and brushing teeth post-platelets (D) require nursing judgment.
The nurse assesses the client diagnosed with acute myeloid leukemia. Which finding should be the nurse’s priority for implementing interventions?
- A. Pain from mucositis and oral tissue injury
- B. Weakness and fatigue with slight activity
- C. T 99°F, P 100, R 22, BP 132/64 mm Hg
- D. Ecchymosis and petechiae noted on arms
Correct Answer: A
Rationale: A. Pain control is priority. The altered VS (other than temperature) could be related to pain. B. Weakness and fatigue are due to anemia and also the disease process. It is important to allow rest, but if pain is not controlled the client may not be able to rest. C. The temperature warrants further monitoring because it could indicate a developing infection; the other VS may decrease if pain is controlled. D. Ecchymosis and petechiae are associated with low platelet counts. The nurse should check the laboratory report for the platelet level, but this is an assessment and not an intervention.