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When assessing the client who is recovering from a radical hysterectomy with vulvectomy, the nurse notes lymphedema of the lower extremities. Which intervention should be implemented by the nurse?
- A. Elevate the head of the client’s bed to 45 degrees.
- B. Increase the client’s intake of fluids high in sodium.
- C. Encourage the client to exercise the lower extremities.
- D. Apply splints to both of the client’s lower extremities.
Correct Answer: C
Rationale: A. Elevating the head of the bed to a 45-degree angle may increase lymphedema of the lower extremities. B. Intake of fluids high in sodium will cause fluid retention. C. Leg exercises will improve drainage when lymphedema is present. D. Lower-extremity splints can cause skin breakdown of edematous tissue.
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Which client should be assigned to the experienced medical-surgical nurse who is in the first week of orientation to the oncology floor?
- A. The client diagnosed with non-Hodgkin’s lymphoma who is having daily radiation treatments.
- B. The client diagnosed with Hodgkin’s disease who is receiving combination chemotherapy.
- C. The client diagnosed with leukemia who has petechiae covering both anterior and posterior body surfaces.
- D. The client diagnosed with diffuse histolytic lymphoma who is to receive two (2) units of packed red blood cells.
Correct Answer: C
Rationale: Leukemia with extensive petechiae (C) indicates severe thrombocytopenia, requiring experienced assessment for bleeding. Radiation (A), chemotherapy (B), and transfusions (D) are less complex.
The nurse is caring for a child who has hemophilia. He is admitted with a bleeding episode. Which of the following should the nurse expect will be given to stop the bleeding?
- A. Heparin
- B. Cryoprecipitate
- C. Packed cells
- D. Whole blood
Correct Answer: B
Rationale: Cryoprecipitate contains clotting factors, such as factor VIII, essential for stopping bleeding in hemophilia.
Which is the primary goal of care for a client diagnosed with sickle cell anemia?
- A. The client will call the HCP if feeling ill.
- B. The client will be compliant with medical regimen.
- C. The client will live as normal a life as possible.
- D. The client will verbalize understanding of treatments.
Correct Answer: C
Rationale: The primary goal for SCA is to live normally (C), managing crises. Calling HCP (A), compliance (B), and understanding (D) are secondary.
A 5-year-old boy is admitted because he bled profusely when he lost his first baby tooth. After a workup, he is diagnosed as having classic hemophilia. His mother asks the nurse if his two younger sisters will also develop hemophilia. What is the best answer for the nurse to give?
- A. They will not develop the disease.'
- B. Statistically, one of them is likely to develop the disease.'
- C. They are not likely to get the disease, but they may be carriers.'
- D. If it doesn't show up by the time they start school, they are unlikely to develop the condition.'
Correct Answer: C
Rationale: Hemophilia is an X-linked recessive disorder. Females are unlikely to develop the disease but may be carriers, especially if the mother is a carrier.
The client is admitted to the emergency department after a motor-vehicle accident. The nurse notes profuse bleeding from a right-sided abdominal injury. Which intervention should the nurse implement first?
- A. Type and crossmatch for red blood cells immediately (STAT).
- B. Initiate an IV with an 18-gauge needle and hang normal saline.
- C. Have the client sign a consent for an exploratory laparotomy.
- D. Notify the significant other of the client’s admission.
Correct Answer: B
Rationale: Profuse bleeding requires immediate IV access with 18-gauge and NS (B) to stabilize hemodynamics. Crossmatch (A), consent (C), and notification (D) follow.