Nokea
Which action should the nurse expect to perform after a client has a bone marrow biopsy taken from the iliac crest?
- A. Apply pressure to the site for one minute
- B. Administer a narcotic analgesic
- C. Apply an adhesive bandage to the site
- D. Place the client in a recumbent position
Correct Answer: C
Rationale: Applying an adhesive bandage to the site after a bone marrow biopsy prevents bleeding and protects the area. Pressure is typically applied for longer, narcotics are not routine, and recumbent positioning is not required.
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The client with O+ blood is in need of an emergency transfusion but the laboratory does not have any O+ blood available. Which potential unit of blood could be given to the client?
- A. The O- unit.
- B. The A+ unit.
- C. The B+ unit.
- D. Any Rh+ unit.
Correct Answer: A
Rationale: O- is the universal donor (A), safe for O+ clients. A+ (B), B+ (C), and other Rh+ (D) risk reactions due to antigens.
The client diagnosed with iron-deficiency anemia is prescribed ferrous gluconate orally. Which should the nurse teach the client?
- A. Take Imodium, an antidiarrheal, over-the-counter (OTC) for diarrhea.
- B. Limit exercise for several weeks until a tolerance is achieved.
- C. The stools may be very dark, and this can mask blood.
- D. Eat only red meats and organ meats for protein.
Correct Answer: C
Rationale: Ferrous gluconate darkens stools (C), potentially masking GI bleeding. Imodium (A) is premature, exercise (B) is encouraged, and diet (D) should be varied, not meat-only.
A college student who is diagnosed as having infectious mononucleosis asks how the disease is spread. The nurse's response is based on the knowledge that the usual mode of transmission is through:
- A. skin.
- B. genital contact.
- C. contaminated water.
- D. intimate oral contact.
Correct Answer: D
Rationale: Infectious mononucleosis, known as the 'kissing disease,' is spread through intimate oral contact, such as kissing or sharing utensils.
Which sign would the nurse expect to assess in the client diagnosed with idiopathic thrombocytopenic purpura (ITP)?
- A. Petechiae on the anterior chest, arms, and neck.
- B. Capillary refill of less than three (3) seconds.
- C. An enlarged spleen.
- D. Pulse oximeter reading of 95%.
Correct Answer: A
Rationale: ITP causes low platelets, leading to petechiae (A). Capillary refill (B) is normal, splenomegaly (C) is not primary, and SpO2 95% (D) is normal.
The client with a primary diagnosis of liver cancer with metastases to the lung is hospitalized with severe dyspnea. The nurse is preparing the client for radiation of the upper chest. Which nursing conclusion about the purpose of radiation therapy for this client is correct?
- A. Radiation therapy is used to cure and control liver cancer.
- B. Radiation therapy is used to prevent future cancer development.
- C. Radiation therapy is used to cure and control lung cancer.
- D. Radiation therapy is used to prevent or relieve distressing symptoms.
Correct Answer: D
Rationale: A. Radiation of the upper chest would have no effect on the liver located in the abdominal cavity. B. Preventing future cancer development is not the intention of radiation therapy for this client. C. Radiation therapy reduces size of tumors but would not be expected to cure cancer in this client. D. Primary liver tumors commonly metastasize to the lung, which can cause obstructive symptoms. In this client, radiation therapy to the lung would be used as a palliative care modality to help relieve distressing symptoms such as dyspnea.