Nokea
The nurse is working in a blood bank facility procuring units of blood from donors. Which client would not be a candidate to donate blood?
- A. The client who had wisdom teeth removed a week ago.
- B. The nursing student who received a measles immunization two (2) months ago.
- C. The mother with a six (6)-week-old newborn.
- D. The client who developed an allergy to aspirin in childhood.
Correct Answer: C
Rationale: Recent childbirth (C) (within 6 months) disqualifies blood donation due to anemia risk. Wisdom teeth (A), immunization (B), and aspirin allergy (D) are not contraindications.
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The nurse administers iron using the Z track technique. What is the primary reason for administering iron via Z track?
- A. To prevent adverse reactions
- B. To prevent staining of the skin
- C. To improve the absorption rate
- D. To increase the speed of onset of action
Correct Answer: B
Rationale: The Z track technique prevents iron from leaking into subcutaneous tissue, reducing skin staining.
The client diagnosed with cancer has been undergoing systemic treatments and has red blood cell deficiency. Which signs and symptoms should the nurse teach the client to manage?
- A. Nausea associated with cancer treatment.
- B. Shortness of breath and fatigue.
- C. Controlling mucositis and diarrhea.
- D. The emotional aspects of having cancer.
Correct Answer: B
Rationale: RBC deficiency (anemia) causes shortness of breath and fatigue (B), which clients should manage. Nausea (A), mucositis/diarrhea (C), and emotions (D) are unrelated to anemia.
The client who was recently admitted with gastric cancer appears pale and weak and states feeling fatigued. In reviewing the client’s laboratory results, which component of the CBC should the nurse most associate with the client’s gastric cancer and identify as the causative factor for the fatigue?
- A. White blood cell 12,200/mm3
- B. Hemoglobin 7.9 g/dL
- C. Serum protein 5.9 g/dL
- D. Blood urea nitrogen 22 mg/dL
Correct Answer: B
Rationale: A. The elevation in the WBC (normal is 4500–10,000/mm3 or microL) is concerning because it could indicate an infection, but the elevation would not necessarily be related to the gastric cancer. B. The presenting symptoms are indicative of anemia, which is common in gastric cancer due to chronic blood loss, or as a result of pernicious anemia (due to loss of intrinsic factor). The low Hgb (normal is 12–15 g/dL) may be the causative factor for the fatigue. C. The serum protein is slightly low (normal is 6.0–8.0 g/dL) and could be indicative of nutritional problems associated with the gastric cancer, but it is not specific to the signs and symptoms described in the question, and it is not part of a CBC. D. The BUN (normal is 5–25 mg/dL) is within normal parameters and is measuring kidney function or hydration status. It is not part of the CBC.
The nurse is admitting a client with a diagnosis of rule-out Hodgkin's lymphoma. Which assessment data support this diagnosis?
- A. Night sweats and fever without 'chills.'
- B. Edematous lymph nodes in the groin.
- C. Malaise and complaints of an upset stomach.
- D. Pain in the neck area after a fatty meal.
Correct Answer: A
Rationale: Night sweats and fever (A) are classic Hodgkin’s B symptoms. Edematous nodes (B) are not typical (firm, non-tender), malaise/stomach (C) is nonspecific, and neck pain (D) suggests gallbladder issues.
The nurse has been teaching the parents of a child with hemophilia about the care he will need. Which statement by the parents indicates a need for more instruction?
- A. If my child needs something for pain or a fever, I will give him acetaminophen instead of aspirin.'
- B. I will take my child to the dentist for regular checkups.'
- C. I will keep my child in the house most of the time.'
- D. My son's Medic Alert Bracelet arrived.'
Correct Answer: C
Rationale: Overprotecting the child by keeping him indoors most of the time prevents normal development. Acetaminophen, dental care, and a Medic Alert bracelet are appropriate.