Nokea
Which mandatory practice is the most effective and significant nursing practice to prevent the spread of infection for a patient with agranulocytosis?
- A. Strict and frequent hand washing by all people having contact with the patient
- B. Placement of patients in private rooms with high-efficiency particulate air (HEPA) filtration
- C. Administration of combinations of prophylactic antibiotics
- D. Creation of a 'sterile' environment for the patient with the use of laminar airflow rooms
Correct Answer: A
Rationale: Meticulous hand washing by medical and nursing personnel and strict asepsis are mandatory.
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When the 14-year-old patient comes into the emergency room in sickle cell crisis, which should be the primary focus of care?
- A. Genetic counseling
- B. Applying ice packs
- C. Pain relief measures
- D. Providing iron replacements
Correct Answer: C
Rationale: Pain control during the crisis is the focus. Continuous opioids are the mainstay of pain management. Genetic counseling would not be appropriate during a crisis. Ice packs would constrict blood vessels, thus contributing to more pain. Iron replacement is not usually given with sickle cell anemia.
Which would the nurse explain as a type of leukemia that affects noticeably more children and teens than adults?
- A. Chronic lymphocytic leukemia (CLL)
- B. Acute myeloid leukemia (AML)
- C. Acute lymphocytic leukemia (ALL)
- D. Chronic myeloid leukemia (CML)
Correct Answer: C
Rationale: The majority of cases of ALL are children under the age of 5 years.
Which is the average lifespan of an erythrocyte?
- A. 7 days
- B. 60 days
- C. 120 days
- D. Up to several years
Correct Answer: C
Rationale: The lifespan of an RBC is 120 days. A WBC's lifespan is days to several years. Platelets live 5 to 9 days.
The nurse examines the complete blood count (CBC) to assess which level?
- A. hematocrit.
- B. red cell count.
- C. differential white blood cell count.
- D. plasma level.
- E. blood type.
- F. hemoglobin.
Correct Answer: A,B,C,F
Rationale: The CBC gives information relative to RBC, WBC, hematocrit, hemoglobin, erythrocyte indexes, WBC differential, and examination of the peripheral blood cells.
The nurse caring for a patient in the emergency room with suspected internal injuries will assess for hypovolemic shock, which is evidenced by which symptom?
- A. irritability.
- B. restlessness.
- C. slow bounding pulse.
- D. decreased respirations.
- E. pallor.
- F. hypotension.
Correct Answer: A,B,E,F
Rationale: Indicators of hypovolemia are restlessness, irritability, rapid thready pulse, increasing respirations, pale, cool moist skin, and hypotension. Should the blood loss continue, the patient could go into hypovolemic shock.