Nokea
The nurse writes a client problem of 'activity intolerance' for a client diagnosed with anemia. Which intervention should the nurse implement?
- A. Pace activities according to tolerance.
- B. Provide supplements high in iron and vitamins.
- C. Administer packed red blood cells.
- D. Monitor vital signs every four (4) hours.
Correct Answer: A
Rationale: Pacing activities (A) conserves energy in anemia-related activity intolerance. Supplements (B) and transfusions (C) are medical, and vitals (D) are routine, not primary.
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The client had basal cell carcinoma (BCC) lesions excised the day before at an outpatient clinic. The client telephones the nurse expressing concerns that the wounds are draining watery, pale pink fluid and that the small dressing is leaking. Which action should the nurse recommend?
- A. Apply ice to the area
- B. Contact the surgeon
- C. Take pain medication
- D. Change the dressings
Correct Answer: D
Rationale: A. Applying ice to the area is not necessary because the client did not mention swelling. B. Since the wounds do not drain purulent material, contacting the physician is not necessary. C. Because the client is not experiencing pain, pain medication is not needed. D. The nurse should recommend changing the dressing because a small amount of serosanguineous drainage is a normal response to surgical removal of a lesion.
The nurse teaches a coworker about the treatment for hemophilia. The nurse instructs that the treatment will likely include periodic self-administration of which component?
- A. Platelets
- B. Whole blood
- C. Factor concentrates
- D. Fresh frozen plasma
Correct Answer: C
Rationale: A. Platelets do not contain the deficient clotting factors. B. Although whole blood contains the deficient factors, periodic administration of factor concentrates are safer. C. A person with hemophilia A is deficient in factor VIII; hemophilia B, factor IX; and von Willebrand’s hemophilia, the von Willebrand’s factor and factor VIII. Recombinant forms of the factors are available for the client to self-administer intravenously at home. D. Although fresh frozen plasma contains the deficient factors, periodic administration of factor concentrates are safer.
Which nursing interventions should the nurse implement when caring for a client diagnosed with hemophilia A? Select all that apply.
- A. Instruct the client to use a razor blade to shave.
- B. Avoid administering enemas to the client.
- C. Encourage participation in noncontact sports.
- D. Teach the client how to apply direct pressure if bleeding occurs.
- E. Explain the importance of not flossing the gums.
Correct Answer: B,C,D
Rationale: Avoiding enemas (B), noncontact sports (C), and teaching pressure (D) prevent bleeding in hemophilia. Razor blades (A) and avoiding flossing (E) increase bleeding risk.
The client receiving hospice care has cancer pain and requires treatment with a co-analgesic for pain control. Which medication should the nurse request an HCP to prescribe because it gives the best pain-relieving response when given with opioids?
- A. Promethazine
- B. Gabapentin
- C. Diphenhydramine
- D. Droperidol
Correct Answer: B
Rationale: Promethazine (Phenergan) is given with pain medications, but it treats nausea and vomiting, not pain. Gabapentin (Neurontin) is often administered with opioid pain medications because of its efficacy in relieving neuropathic pain and its limited adverse effects. Diphenhydramine (Benadryl) is not a co-analgesic but an antihistamine. Droperidol (Inapsine) is not a co-analgesic but an antiemetic to control nausea and vomiting.
The nurse is caring for the client experiencing superior vena cava syndrome secondary to lung cancer. Which problem should be the nurse’s priority?
- A. Ineffective breathing pattern
- B. Ineffective tissue perfusion
- C. Risk for infection
- D. Impaired skin integrity
Correct Answer: A
Rationale: A. Ineffective breathing pattern occurs with superior vena cava syndrome because the superior vena cava is located next to the main stem bronchus and causes compression of the intrathoracic structures. B. Ineffective tissue perfusion may occur with superior vena cava syndrome, but ineffective breathing pattern is priority. C. Risk for infection occurs with chemotherapy treatment and not from superior vena cava syndrome. D. Impaired skin integrity occurs with malignant skin conditions and usually not from lung cancer.