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Which sign/symptom will the nurse expect to assess in the client diagnosed with a vaso-occlusive sickle cell crisis?
- A. Lordosis.
- B. Epistaxis.
- C. Hematuria.
- D. Petechiae.
Correct Answer: C
Rationale: Vaso-occlusive crisis causes ischemia; hematuria (C) results from renal infarction. Lordosis (A) is spinal, epistaxis (B) is bleeding, and petechiae (D) indicate thrombocytopenia.
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The client is admitted with a diagnosis of colon cancer. Which finding in the client’s admission information should prompt the nurse to consider that the cancer may be located in the client’s descending colon?
- A. Pain in the lower abdomen
- B. Change in bowel habits
- C. Bright red blood in the stool
- D. Nausea and vomiting
Correct Answer: C
Rationale: A. Pain may be a symptom of a tumor located on the left side of the colon, but it is not exclusive and could be a symptom of a tumor elsewhere in the colon. B. Change of bowel habits may be a symptom of a tumor located on the left side of the colon, but this is not exclusive and could be a symptom of a tumor elsewhere in the colon. C. Bright red blood in the stool is a sign or symptom of a colorectal tumor located in the descending colon. D. Nausea and vomiting are not symptoms specific to colon cancer.
The client is diagnosed with polycythemia vera. The nurse would prepare to perform which intervention?
- A. Type and crossmatch for a transfusion.
- B. Assess for petechiae and purpura.
- C. Perform phlebotomy of 500 mL of blood.
- D. Monitor for low hemoglobin and hematocrit.
Correct Answer: C
Rationale: Polycythemia vera requires phlebotomy (C) to reduce blood viscosity. Transfusions (A) worsen hyperviscosity, petechiae (B) are for thrombocytopenia, and Hb/Hct (D) are elevated.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on an oncology floor. Which nursing task would be delegated to the UAP?
- A. Assess the urine output on a client who has had a blood transfusion reaction.
- B. Take the first 15 minutes of vital signs on a client receiving a unit of PRBCs.
- C. Auscultate the lung sounds of a client prior to a transfusion.
- D. Assist a client who received 10 units of platelets in brushing the teeth.
Correct Answer: B
Rationale: Taking initial vital signs (B) during transfusion is within UAP scope. Assessing urine (A), lung sounds (C), and brushing teeth post-platelets (D) require nursing judgment.
The nurse assesses the client diagnosed with acute myeloid leukemia. Which finding should be the nurse’s priority for implementing interventions?
- A. Pain from mucositis and oral tissue injury
- B. Weakness and fatigue with slight activity
- C. T 99°F, P 100, R 22, BP 132/64 mm Hg
- D. Ecchymosis and petechiae noted on arms
Correct Answer: A
Rationale: A. Pain control is priority. The altered VS (other than temperature) could be related to pain. B. Weakness and fatigue are due to anemia and also the disease process. It is important to allow rest, but if pain is not controlled the client may not be able to rest. C. The temperature warrants further monitoring because it could indicate a developing infection; the other VS may decrease if pain is controlled. D. Ecchymosis and petechiae are associated with low platelet counts. The nurse should check the laboratory report for the platelet level, but this is an assessment and not an intervention.
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.