Nokea
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.
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Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia?
- A. Potential complication: seizures
- B. Potential complication: infection
- C. Potential complication: neurogenic shock
- D. Potential complication: pulmonary edema
Correct Answer: B
Rationale: The correct answer is B: Potential complication: infection. Patients with idiopathic aplastic anemia have pancytopenia, which puts them at a high risk for infections due to decreased production of all blood cells (red blood cells, white blood cells, and platelets). Infection is a significant concern in these patients. Choices A, C, and D are incorrect because seizures, neurogenic shock, and pulmonary edema are not typically associated with idiopathic aplastic anemia. While seizures can occur in some conditions that affect the brain, neurogenic shock is related to spinal cord injury, and pulmonary edema is more commonly seen in conditions like heart failure.
A 44-year-old with sickle cell anemia who says his eyes always look sort of yellow
- A. A 23-year-old with no previous health problems who has a nontender lump in the axilla
- B. A 50-year-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue
- C. A 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement
- D. A 44-year-old with sickle cell anemia who says his eyes always look sort of yellow
Correct Answer: B
Rationale: Choice B is the correct answer because the scenario describes a 50-year-old with early-stage chronic lymphocytic leukemia who presents with chronic fatigue. Chronic lymphocytic leukemia commonly presents with symptoms like fatigue, weight loss, and enlarged lymph nodes. The other choices are less likely as they do not match the clinical presentation described in the scenario. Choice A describes a 23-year-old with a nontender lump in the axilla, which is more suggestive of a benign condition like a lipoma. Choice C describes a 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement, which is unrelated to the symptoms of chronic lymphocytic leukemia. Choice D repeats the scenario, which is not relevant in selecting the appropriate answer.
Which menu choice indicates that the patient understands the nurse's teaching about recommended dietary choices for iron-deficiency anemia?
- A. Omelet and whole wheat toast
- B. Cantaloupe and cottage cheese
- C. Strawberry and banana fruit plate
- D. Cornmeal muffin and orange juice
Correct Answer: D
Rationale: The correct answer is D: "Cornmeal muffin and orange juice." Cornmeal muffin is a good source of iron, which is beneficial for individuals with iron-deficiency anemia. Orange juice is high in vitamin C, which aids in iron absorption. Choices A, B, and C do not specifically address the need for iron-rich foods, making them less suitable for someone with iron-deficiency anemia. Omelet and whole wheat toast (Choice A) may provide some iron but are not as focused on addressing the specific deficiency. Cantaloupe and cottage cheese (Choice B) and strawberry and banana fruit plate (Choice C) are more general fruit choices and do not emphasize iron-rich options.
The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take before this procedure?
- A. Check for any iodine allergy.
- B. Insert a large-bore IV catheter.
- C. Administer prescribed sedatives.
- D. Assist the patient to a flat position.
Correct Answer: D
Rationale: Before a liver and spleen scan, it is essential to assist the patient to a flat position. This position helps obtain clear images of the liver and spleen. Checking for iodine allergy (Choice A) is more relevant for procedures involving contrast dye, not a liver and spleen scan. Inserting a large-bore IV catheter (Choice B) may not be necessary for this specific procedure. Administering sedatives (Choice C) is not typically required for a liver and spleen scan, as the patient needs to remain still during the procedure.
A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to
- A. administer oxygen therapy at a high flow rate
- B. obtain a urine specimen to send to the laboratory
- C. notify the healthcare provider about the symptoms
- D. disconnect the transfusion and infuse normal saline
Correct Answer: D
Rationale: The patient's symptoms, back pain, and difficulty breathing after the transfusion indicate a possible acute hemolytic reaction, a severe transfusion reaction. The priority action in this situation is to discontinue the transfusion immediately to prevent further complications. Infusing normal saline helps maintain the patient's intravascular volume and prevent renal damage. Administering oxygen or obtaining a urine specimen is not the most urgent action and could delay essential treatment. Notifying the healthcare provider is important but should come after ensuring the patient's safety by stopping the blood transfusion.