Nokea
Which of the following would the nurse identify as an abnormal finding?
- A. Red blood cells (RBCs): 4.9million/ul
- B. Hematocrit: 45%
- C. Platelets: 115,000/ul
- D. None of the above
Correct Answer: C
Rationale: The nurse would identify platelets at 115,000/ul as an abnormal finding because it is below the normal range of 150,000-450,000/ul. Low platelet count can lead to increased bleeding risk. RBC count and hematocrit levels are within normal ranges, making them normal findings. Option D is incorrect as platelets are abnormal.
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Which client statement would indicate to the nurse that the client with polycythemia vera is in need further of instruction?
- A. I’ll be flying overseas to see my son and grandchildren for the holidays
- B. I plan to do my leg exercises at least three times a week
- C. I’m going to be walking in the mall everyday to build up my strength
- D. At night when I sleep, I like to use two pillows to raise my head up CARING FOR CLIENTS FOR DISORDERS OF THE LYMPHATIC SYSTEM
Correct Answer: D
Rationale: The correct answer is D because using two pillows to raise the head can increase the risk of venous stasis and thrombosis in a client with polycythemia vera. This condition involves an increased production of red blood cells, leading to thicker blood and potential clot formation. Elevating the head too much can impede blood flow, exacerbating the risk of clotting. Choices A, B, and C are all appropriate statements indicating good self-care practices and physical activity, which are beneficial for clients with polycythemia vera to improve circulation and overall health.
The nurse is developing a plan of care for marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable?
- A. 24 hours
- B. 7 to 14 days
- C. 2 to 4 days
- D. 21 to 28 days
Correct Answer: B
Rationale: The correct answer is B: 7 to 14 days. Marrow suppression from floxuridine typically occurs 1-2 weeks after administration due to its effects on rapidly dividing cells in the bone marrow. This is known as the nadir period. Choices A, C, and D are incorrect because 24 hours is too soon for noticeable effects, 2 to 4 days is too short for the nadir period, and 21 to 28 days is too long for the onset of marrow suppression. The correct choice aligns with the expected timeframe for floxuridine's impact on bone marrow function.
The following are known to be causes of hepatitis except:
- A. virus
- B. toxin
- C. bacteria
- D. chemicals and drugs
Correct Answer: C
Rationale: The correct answer is C: bacteria. Hepatitis is primarily caused by viruses (such as Hepatitis A, B, C), toxins (like alcohol or certain medications), and chemicals/drugs. Bacteria do not typically cause hepatitis as it is a viral infection that affects the liver. Therefore, choice C is the exception among the listed causes. Viruses directly target liver cells, toxins can damage the liver, and certain chemicals/drugs can lead to liver inflammation. Hence, bacteria do not play a significant role in causing hepatitis.
25-year old Francisco M., is diagnosed as having myelocytic leukemia and is admitted for chemotherapy. Francisco M.’s laboratory results indicate bone marrow depression. The nurse should encourage him to:
- A. Sleep with the head of the bed slightly
- B. Use a soft toothbrush and electric razor
- C. Drink citrus juices frequently for nourishment
- D. Increase his activity level and ambulates frequently
Correct Answer: B
Rationale: The correct answer is B: Use a soft toothbrush and electric razor. Patients with bone marrow depression are at increased risk of bleeding due to low platelet count. Using a soft toothbrush and electric razor helps prevent injury to the gums and skin, reducing the risk of bleeding. Choices A, C, and D are incorrect because:
A: Sleeping with the head of the bed slightly elevated is not directly related to preventing bleeding in bone marrow depression.
C: Drinking citrus juices may irritate the stomach lining and are not specifically indicated for preventing bleeding.
D: Increasing activity level and frequent ambulation may increase the risk of injury and bleeding in a patient with bone marrow depression.
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
- A. Begin with introductions.
- B. Ask about the chief concerns or problems.
- C. Explain that the interview will be over in a few minutes.
- D. Tell the patient “I will be back to administer medications in 1 hour.”
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems.
Rationale:
1. This step follows setting the agenda to focus on patient's main issues.
2. Allows nurse to gather essential information for effective care.
3. Builds rapport and shows patient-centered approach.
Summary of other choices:
A: Introductions are typically done at the beginning of the interview.
C: Prematurely ending the interview may hinder rapport and information gathering.
D: Administering medications is not the immediate priority after setting the agenda.