Nokea
Which action will the admitting nurse include in the care plan for a patient who has neutropenia?
- A. Avoid intramuscular injections
- B. Check temperature every 4 hours
- C. Omit fruits or vegetables from the diet
- D. Place a 'No Visitors' sign on the door
Correct Answer: B
Rationale: The correct answer is B: 'Check temperature every 4 hours.' Neutropenic patients have a weakened immune system due to low levels of neutrophils, which are a type of white blood cell that helps fight infections. Monitoring the patient's temperature every 4 hours is crucial because the earliest sign of infection in a neutropenic patient is often a fever. This allows for early detection of any potential infections. Choices A, C, and D are incorrect because avoiding intramuscular injections, omitting fruits or vegetables from the diet, and placing a 'No Visitors' sign on the door are not specific actions directly related to managing neutropenia or monitoring for signs of infection.
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When providing care for a patient with sickle cell crisis, what is important for the nurse to do?
- A. Monitor the patient's intake of oral and IV fluids
- B. Evaluate the effectiveness of opioid analgesics
- C. Encourage the patient to ambulate as much as tolerated
- D. Educate the patient about high-protein, high-calorie foods
Correct Answer: B
Rationale: The correct answer is to evaluate the effectiveness of opioid analgesics. In sickle cell crisis, pain is the most common symptom and is usually managed with large doses of continuous opioids. Monitoring fluid intake (Choice A) is important, but limiting fluids may not be necessary. Encouraging ambulation (Choice C) is generally good but may not be the priority during a sickle cell crisis. Educating the patient about nutrition (Choice D) is important for overall health but may not be the immediate focus during a crisis.
Which task for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?
- A. Assessing the patient for signs and symptoms of infection
- B. Teaching the patient the purpose of neutropenic precautions
- C. Administering subcutaneous filgrastim (Neupogen) injection
- D. Developing a discharge teaching plan for the patient and family
Correct Answer: C
Rationale: The correct answer is C because administering subcutaneous medications falls within the education and scope of practice of an LPN/LVN. Assessing the patient for signs and symptoms of infection, teaching the patient, and developing a discharge plan are tasks that require an RN level of education and scope of practice. LPN/LVNs can assist in patient care, but tasks that involve assessment, teaching, and care planning are typically the responsibility of an RN.
A 52-year-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states:
- A. I need to start eating more red meat and liver.
- B. I will stop having a glass of wine with dinner.
- C. I could choose nasal spray rather than injections of vitamin B12.
- D. I will need to take a proton pump inhibitor such as omeprazole (Prilosec).
Correct Answer: C
Rationale: The correct answer is C. Pernicious anemia is a condition where the body can't absorb enough vitamin B12. Treatment usually involves lifelong replacement of vitamin B12. In this case, the patient understanding the disorder is correctly demonstrated by choosing nasal spray or injections of vitamin B12 for replacement therapy. Choices A, B, and D are incorrect because increasing red meat/liver intake, stopping wine consumption, or taking a proton pump inhibitor like omeprazole do not address the primary issue of vitamin B12 absorption in pernicious anemia.
The nurse is caring for a patient who is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching?
- A. Check frequently for swollen lymph nodes.
- B. Watch for excessive bleeding or bruising.
- C. Take iron supplements to prevent anemia.
- D. Wash hands regularly and avoid individuals who are ill.
Correct Answer: D
Rationale: The correct answer is D: 'Wash hands regularly and avoid individuals who are ill.' After a splenectomy, the patient is at an increased risk of infection, particularly from gram-positive bacteria. Proper hand hygiene and avoiding contact with sick individuals are crucial to prevent infections. Choices A, B, and C are incorrect because checking for swollen lymph nodes, watching for excessive bleeding or bruising, and taking iron supplements are not specifically related to the increased infection risk post-splenectomy.
A patient is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching?
- A. Check frequently for swollen lymph nodes.
- B. Watch for excessive bleeding or bruising.
- C. Take iron supplements to prevent anemia.
- D. Wash hands and avoid individuals who are ill.
Correct Answer: D
Rationale: The correct answer is D. After a splenectomy, the patient is at an increased risk of infection, particularly from gram-positive bacteria. Washing hands and avoiding contact with individuals who are ill are crucial to reduce this risk. Choice A is incorrect because checking for swollen lymph nodes is not a priority after a splenectomy. Choice B is incorrect as while bleeding is a concern, it is more immediate post-operatively. Choice C is incorrect as iron supplements do not specifically relate to the risk of infection post-splenectomy.