Nokea
The young adult, diagnosed with hemophilia A, is receiving a monthly scheduled dose of factor VIII cryoprecipitate. The client begins to cry during administration. Which response by the nurse is most appropriate?
- A. “Why are you crying? You seem afraid when I am administering the drug.”
- B. “Is it painful while I’m giving this IV push? If so, I can give it by infusion.”
- C. “I know this is uncomfortable for you; this only takes a few minutes to give.”
- D. “If you want to talk to me about what you are feeling, I am here to listen.”
Correct Answer: D
Rationale: A. Asking a “why” question challenges the client’s feelings. B. This response seeks information but is not most appropriate. It is unlikely that the initial response from an adult would not be crying if the administration of IV factor VIII cryoprecipitate by IV push were painful. C. This response ignores the client’s feelings and presumes that the nurse knows what initiated the client’s crying. D. The nurse is offering self, which is a therapeutic communication technique.
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The nurse is administering vesicant chemotherapy medications such as doxorubicin hydrochloride to clients. Which nursing actions should the nurse implement to prevent extravasation?
- A. Give through an IV catheter in a large peripheral vein if infusing in less than 60 minutes.
- B. Check patency every 5 to 10 minutes during infusion and ask about IV site discomfort.
- C. Check the IV pump and alarm for indications of an infiltration of the medication.
- D. Check for blood return in a central venous catheter prior to administration of the vesicant.
- E. Use small-gauged syringes with small barrels when flushing any access devices with saline.
Correct Answer: A, B, D
Rationale: A peripheral IV catheter may be used for a vesicant if administration time is less than 60 minutes, a large vein is used, and there is careful monitoring of the IV site. B. Checking for patency and asking about discomfort at the IV site will help prevent an infiltration. C. IV pumps and alarms cannot be relied upon to detect extravasation because infiltration usually does not cause sufficient pressure to trigger an alarm. D. Checking for blood return in the central venous catheter prior to administration will help ensure that the medication is being administered into a vessel and not into tissues. E. Small-gauge syringes with small barrels produce high pressures and may cause injury to the blood vessel or may damage a central line catheter and should not be used.
Following morning shift report, the nurse identifies care needs for four clients. Which client should be the nurse’s priority?
- A. The client with lung cancer who is to receive ondansetron 8 mg IV 30 minutes prior to chemotherapy
- B. The client with an absolute neutrophil count of 98/mm3 who needs to be placed on neutropenic precautions
- C. The client who is stable but has breast cancer and is scheduled for external beam radiation in 15 minutes
- D. The client with stomatitis from radiation for tonsillar cancer who is to receive a gastrostomy tube feeding
Correct Answer: B
Rationale: A. No time is noted for the administration of ondansetron (Zofran) prior to chemotherapy treatment; this client is not the nurse’s priority. B. The client with neutropenia should be the nurse’s priority. If seen first, microorganisms from other clients would be less likely to be transmitted to the client. This client is at risk for infection and severe sepsis because the absolute neutrophil count is less than 1001mm3 (normal = 1500 to 8000/mm3). C. This client is stable; another person can take this client to radiation therapy, and the nurse’s assessment can wait until the client returns. D. The tube feeding can be initiated after the needs of the most critical client are met.
The nurse is assessing a client diagnosed with vaso-occlusive crisis. Which indicates the client is not meeting an appropriate stage of growth and development according to Erikson?
- A. The 32-year-old client does not have a significant other and is on disability.
- B. The 28-year-old client is actively involved in the care of a six (6)-year-old child.
- C. The 40-year-old client has a full-time job and cares for an aged parent.
- D. The 19-year-old client is a full-time college student and has many friends.
Correct Answer: A
Rationale: At 32 (Intimacy vs. Isolation), lack of a significant other and disability (A) suggest isolation, not meeting Erikson’s stage. Parenting (B), caregiving (C), and socializing (D) align with Generativity, Generativity, and Identity stages.
A child who has hemophilia is admitted to the hospital with a swollen knee joint. He is complaining of severe pain. What is the priority of nursing care for this child upon admission?
- A. Maintain joint function
- B. Use a bed cradle
- C. Administer aspirin as needed for pain
- D. Encourage fluids
Correct Answer: B
Rationale: Using a bed cradle reduces pressure on the swollen, painful joint, prioritizing pain relief and comfort during a bleeding episode.
An elderly client who is being treated for pernicious anemia needs to be monitored periodically for which of the following conditions?
- A. Lactose intolerance
- B. Stomach cancer
- C. Dementia
- D. Hearing loss
Correct Answer: B
Rationale: Pernicious anemia is associated with an increased risk of stomach cancer due to chronic gastritis, requiring periodic monitoring.