Nokea
The nurse provides education to a patient with thrombocytopenia about precautions to be taken at home. The nurse identifies that further teaching is needed when the patient performs which action?
- A. Drinks 14 glasses of water daily.
- B. Shaves once a day using an electric razor.
- C. Uses an alcohol-based mouthwash twice a day.
- D. Brushes teeth with a soft-bristle toothbrush twice a day.
Correct Answer: C
Rationale: Alcohol-based mouthwash can cause mucosal irritation and bleeding, inappropriate for thrombocytopenia, suggesting further education is needed.
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Which information would the nurse include when discussing pain due to chronic stable angina with the patient?
- A. Occurs with both activity and rest.
- B. Generally lasts 10-15 minutes or more.
- C. Does not subside when the precipitating factor is resolved.
- D. Occurs intermittently over a period of time in a similar pattern.
Correct Answer: D
Rationale: Chronic stable angina occurs intermittently in a predictable pattern, triggered by exertion and relieved by rest or nitroglycerin.
Which explanation will the nurse give a patient with non-Hodgkin lymphoma about the purpose of a planned lumbar puncture?
- A. To rule out any bone marrow involvement.
- B. To determine the level of cell differentiation.
- C. To establish which lymph cell type is involved.
- D. To find any central nervous system involvement.
Correct Answer: D
Rationale: A lumbar puncture in non-Hodgkin lymphoma is used to detect central nervous system involvement by examining cerebrospinal fluid for lymphoma cells.
Which information will the nurse include when teaching a patient who is receiving chemotherapy for leukemia?
- A. The treatment has severe side effects, some of which will be permanent.
- B. You need to use your call light to ask for help every time you get out of bed.
- C. Prevention and early detection of infection are important during leukemia treatment.
- D. Feeling isolated is a common and unavoidable consequence of leukemia treatment.
Correct Answer: C
Rationale: Prevention and early detection of infection are critical during leukemia chemotherapy due to immune suppression, a key patient education point.
After noting that a patient with leukemia has thrombocytopenia, which action will the nurse plan to take?
- A. Palpate lymph nodes for swelling.
- B. Check temperature for elevation.
- C. Inspect skin for bruising or petechiae.
- D. Examine oral mucosa for ulceration.
Correct Answer: C
Rationale: Inspecting the skin for bruising or petechiae is specific to thrombocytopenia, as petechiae are small, red or purple dots that appear on the skin when platelet count is low, indicating a bleeding tendency.
Which arterial blood gas (ABG) data corresponds with a patient's clinical manifestations of respiratory alkalosis?
- A. pH = 7.46, PaCO2 = 44 mm Hg, PaO2 = 95 mm Hg, and HCO3 = 36 mEq/L.
- B. pH = 7.27, PaCO2 = 70 mm Hg, PaO2 = 80 mm Hg, and HCO3 = 26 mEq/L.
- C. pH = 7.30, PaCO2 = 35 mm Hg, PaO2 = 70 mm Hg, and HCO3 = 20 mEq/L.
- D. pH = 7.52, PaCO2 = 24 mm Hg, PaO2 = 85 mm Hg, and HCO3 = 24 mEq/L.
Correct Answer: D
Rationale: Respiratory alkalosis is characterized by a high pH (>7.45) and a low PaCO2 (<35 mm Hg). The data in option D (pH = 7.52, PaCO2 = 24 mm Hg) indicates respiratory alkalosis.