Nokea
Which explanation will the nurse give a patient with non-Hodgkin lymphoma about the purpose of a planned lumbar puncture?
- A. To rule out any bone marrow involvement.
- B. To determine the level of cell differentiation.
- C. To establish which lymph cell type is involved.
- D. To find any central nervous system involvement.
Correct Answer: D
Rationale: A lumbar puncture in non-Hodgkin lymphoma is used to detect central nervous system involvement by examining cerebrospinal fluid for lymphoma cells.
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The nurse provides education to a patient with thrombocytopenia about precautions to be taken at home. The nurse identifies that further teaching is needed when the patient performs which action?
- A. Drinks 14 glasses of water daily.
- B. Shaves once a day using an electric razor.
- C. Uses an alcohol-based mouthwash twice a day.
- D. Brushes teeth with a soft-bristle toothbrush twice a day.
Correct Answer: C
Rationale: Using alcohol-based mouthwash can irritate oral mucosa and cause bleeding in thrombocytopenia, indicating a need for further teaching.
Which fluid replacement therapy would the nurse prepare to administer for a patient who is exhibiting clinical manifestations of hypovolemic shock?
- A. 0.459% saline.
- B. 0.9% NaCl.
- C. 5% dextrose in 0.45% saline.
- D. Dextran.
Correct Answer: B
Rationale: 0.9% NaCl (normal saline) is an isotonic solution ideal for hypovolemic shock, expanding intravascular volume without causing fluid shifts.
With which term will the nurse document the finding after noting multiple 1-mm red macules when assessing the skin of a patient with leukemia and thrombocytopenia?
- A. Purpura.
- B. Bruising.
- C. Petechiae.
- D. Ecchymosis.
Correct Answer: C
Rationale: Petechiae are small, red or purple 1-mm macules due to minor bleeding from broken capillaries, common in thrombocytopenia.
Which change occurs first, making patients susceptible to coronary artery disease?
- A. Formation of thrombus in the coronary artery.
- B. Formation of fibrous plaque in the endothelium.
- C. Reduction of blood flow through the coronary arteries.
- D. Development of fatty streaks in the smooth muscles of the endothelium.
Correct Answer: D
Rationale: Development of fatty streaks in the endothelium is the initial change in atherosclerosis, predisposing patients to coronary artery disease.
Which information would the nurse include when discussing pain due to chronic stable angina with the patient?
- A. Occurs with both activity and rest.
- B. Generally lasts 10-15 minutes or more.
- C. Does not subside when the precipitating factor is resolved.
- D. Occurs intermittently over a period of time in a similar pattern.
Correct Answer: D
Rationale: Chronic stable angina occurs intermittently in a predictable pattern, triggered by exertion and relieved by rest or nitroglycerin.