Question 1

The nurse provides care for a client diagnosed with polycythemia vera. Which statement by the client would require immediate follow-up?

Accepted Answer

Polycythemia vera (PV) is a hematological disorder in which too many RBCs (and often WBCs and platelets) are produced, causing increased blood viscosity, venous stasis, and increased risk for thrombus formation. The nurse should teach clients with PV measures to prevent thrombus (eg, wearing graduated compression stockings, elevating legs when sitting, maintaining adequate hydration). Clients should also learn to monitor for and report signs and symptoms of thrombus (eg, redness, tenderness, or swelling in one leg). Reports of possible thrombus require immediate intervention to avoid serious injury (eg, stroke, pulmonary embolism) (Option B). (Option A) Venous stasis causes the skin on the face, hands, and feet to become ruddy (red). This is an expected finding. (Option C) Occasional headaches or blurred vision can result from sluggish, viscous blood flow in the brain. Aspirin therapy is used for its antiplatelet and analgesic action. The nurse should assess the client's headaches; however, they are not the priority. (Option D) Pruritis is a common occurrence in clients with PV, often after bathing. Clients should bathe with cool water and pat (not rub) themselves dry with a towel to avoid histamine release and use antihistamine creams for relief. Venous stasis can also cause itching, and aspirin can help. Educational objective: Clients with polycythemia vera are at risk for developing thrombus due to increased blood viscosity and stasis. Signs of thrombus (eg, swelling, redness, or tenderness in one leg) require immediate follow-up to avoid embolization and stroke or pulmonary embolism.

Question 2

The nurse is admitting a client who had mastectomy 6 months ago and is scheduled for elective surgery.  During the physical assessment, the nurse notices a 0.5 cm mobile, firm, nontender lymph node in the upper arm.  What action should the nurse take?

Accepted Answer

Ordinarily, lymph nodes are not palpable in adults. However, a lymph node that is palpable, superficial, small (0.5-1 cm), mobile, firm, and nontender is considered a normal finding. It could easily be explained by the relatively recent mastectomy (trauma) with resulting inflammation and lymph flow interference. A tender, hard, fixed, or enlarged node is an abnormal finding. Tender nodes are usually due to inflammation but hard or fixed nodes could indicate malignancy. (Option A) A biopsy is performed for an abnormal lymph node finding that could suggest malignancy. (Option B) The swelling is caused by inadequate lymph drainage or inflammation, not localized edema. Ice is not recommended for this normal finding. (Option D) There is no indication of lymphangiitis requiring antibiotics. This may produce a red streak with induration following the course of the lymphatic collecting duct. Infected skin lesions may also be present. Educational objective: A lymph node that is superficial, palpable, small (≤1 cm ), mobile, firm, and nontender is a normal finding. Hard and fixed nodes are most concerning as they are likely due to malignancy. Tender nodes usually indicate inflammation/infection.

Question 3

The nurse provides home care education to a client newly diagnosed with von Willebrand disease. Which of the following client statements demonstrate correct understanding of the education? Select all that apply.

Accepted Answer

Von Willebrand disease is a genetic bleeding disorder caused by a deficiency of von Willebrand factor (vWF), which plays an important role in coagulation. Intranasal desmopressin or topical therapies (eg, thrombin) may be prescribed to stop minor bleeding, whereas major bleeding may require replacement of vWF. Clients should wear medical identification bracelets in case of emergency. Client teaching includes: Notify the health care provider of signs of bleeding (eg, severe joint pain or swelling, headache [especially after injury], blood in urine/stool, uncontrollable nosebleed). Use a humidifier or nasal spray to keep the mucosa moist, reducing the risk of nosebleeds (Option A). Avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). Avoid activities with a higher risk for injury (eg, contact sports) (Option B). Maintain gum integrity (eg, soft-bristled toothbrush, gentle flossing) to minimize bleeding potential (Option C). Report heavy menstrual bleeding (eg, soaking a pad in <3 hours), which can be managed with hormonal therapies and intranasal desmopressin (Option D). (Option E) Clients should avoid medications that can exacerbate bleeding, including aspirin and NSAIDs (eg, ibuprofen, naproxen, ketorolac). Clients should instead use the mnemonic RICE (rest, ice, compression, elevation) to help with pain and inflammation. Educational objective: In von Willebrand disease, a genetic bleeding disorder, deficient von Willebrand factor prevents effective coagulation. Clients can decrease bleeding risk by avoiding high-risk activities (eg, contact sports) and nonsteroidal anti-inflammatory drugs, keeping nasal mucosa moist, and maintaining gum integrity (eg, soft-bristled toothbrush).

Question 4

A client on a medical-surgical unit is receiving heparin therapy. Platelet levels decreased from 230,000/mm³ (230 × 10⁹/L) 2 days ago to 80,000/mm³ (80 × 10⁹/L) today. Which nursing actions are appropriate? Select all that apply.

Accepted Answer

A significant reduction in platelets after initiation of heparin therapy can indicate heparin-induced thrombocytopenia (HIT), a severe, potentially lethal complication. HIT is an immune reaction to heparin that causes a drastic decrease of ≥50% in platelets and a paradoxical increase in arterial and venous thrombosis. The nurse should notify the health care provider immediately and anticipate stopping heparin therapy and initiating a non-heparin anticoagulant (eg, warfarin, rivaroxaban, argatroban) (Options B and C). Clients with HIT have increased risk for deep venous thrombosis (DVT) and pulmonary embolism. The nurse should perform a neurovascular assessment and report evidence of vascular clots (eg, DVT) to the health care provider. The nurse should also measure a full set of vital signs to assess for pulmonary embolism (eg, tachycardia, tachypnea, decreased oxygen saturation) (Option D). When large changes are noted in laboratory values, it is important to draw repeat samples to confirm those values, as errors in sampling or specimen handling could result in inappropriate intervention (Option A). (Option E) Clients who are suspected of having HIT or who have a history of HIT should never receive heparin or low-molecular-weight heparin (eg, enoxaparin). Only non-heparin anticoagulants may be given. Educational objective: The nurse should suspect heparin-induced thrombocytopenia in a client who is receiving or has recently received heparin and has a sudden reduction of ≥50% in platelet count. The nurse should stop heparin immediately, assess vital signs and neurovascular status, draw blood for repeat testing, and report findings to the health care provider.

Question 5

The nurse receives report on the assigned team of clients on the oncology unit. All are receiving chemotherapy. Which client should the nurse check on first?

Accepted Answer

A new-onset finding is more concerning than chronic or expected findings. There is a risk of spinal cord compression from a metastatic tumor in the epidural space. The classic symptoms are localized, persistent back pain; motor weakness; and sensory changes (eg, numbness, paresthesia). There can also be autonomic dysfunction, reflected by bowel or bladder dysfunction. Neurologic changes are a priority because the symptoms are subtle and time sensitive for permanent negative outcomes. Bone is a common site for metastasis due to its vascularity. This is the highest risk of the 4 options. (Option A) Cells with rapid turnover take up the chemotherapy and are most affected. Commonly expected findings are alopecia (loss of hair) and mucositis/ulcers in the mouth/gastrointestinal system. Comfort care and teaching will be given for these signs, but they are not a priority over a neurologic abnormality. (Option B) Chemotherapy suppresses bone marrow, commonly resulting in neutropenia (low neutrophil count), anemia (low hemoglobin), and thrombocytopenia (low platelets). This would be monitored but is not an emergency at this current level. (Option D) Nausea and vomiting are expected side effects of chemotherapy and/or radiation treatment. Potassium losses occur with vomiting or diarrhea. However, this potassium result is only slightly lowered. It should be monitored but is not the priority compared to the new neurologic assessment. Educational objective: The client with cancer who experiences a new unexpected neurologic complication is a priority. Acute symptoms of spinal cord compression are a priority over stabilized anemia, minor hypokalemia, mucositis, or alopecia.

Question 6

A nurse is caring for a client 1 day after a left-sided mastectomy with lymph node dissection. Which nursing intervention is the priority in caring for this client?

Accepted Answer

After a mastectomy, an important goal is restoring function in the client's affected arm. Measures to promote function are initiated immediately after surgery. Elevating the affected arm to heart level (eg, on a pillow) is crucial to reduce fluid retention and prevent lymphedema in the affected arm (Option B). Hand and arm exercises are implemented gradually, beginning with finger flexion and extension. These activities maintain muscle tone, prevent contractures, and improve lymph and blood circulation, which promote function and also prevent lymphedema. The return of full range of motion in the affected arm is desired within 4-6 weeks. Additional nursing care for clients after a mastectomy includes keeping the client in semi-Fowler position and placing a sign over the bed that specifies, "No blood pressure, venipuncture, or injections on left arm," as these actions could cause lymphedema. (Option A) Ice reduces inflammation, swelling, and pain. Although this reduces discomfort, it does not directly contribute to restoring arm function and is not the priority. (Option C) Frequent ambulation is not the priority in the initial postoperative period as it does not facilitate lymph drainage or help restore arm function. (Option D) Pneumatic compression devices may be used to facilitate lymph drainage when lymphedema is present. Elevating and exercising the arm help prevent lymphedema from developing and are priority in this client. Educational objective: A priority goal for a client following a mastectomy is restoring function in the affected arm. Elevation of the arm and institution of arm exercises begin immediately following surgery to prevent lymphedema.

Question 7

Thrombotic thrombocytopenic purpura is suspected due to the client's current platelet count of 2,000/mm³ (2 x 10⁹/L). Which client sign or symptom is the most concerning and requires immediate further nursing action?

Accepted Answer

Thrombotic thrombocytopenic purpura (TTP) consists of hemolytic anemia with fragmentation of erythrocytes, signs of intravascular hemolysis, thrombocytopenia, decreased renal function, and fever. Regardless of the cause of the low platelets, the concern in this case is the critically low (below 10,000/mm³ (10 x 10⁹/L) platelet count, which puts this client at risk for internal bleeding, especially within the brain. Change in level of consciousness is the most clinically significant finding requiring an emergency response. (Option A) The head is very vascular, and a nosebleed can occur with low platelets. A nosebleed is treated with direct pressure and application of cold. In this client, potential intracranial bleeding is the priority. direct pressure (Option B) Easy bruising can occur as a result of low platelets. However, the bruise is "old," and potential intracranial bleeding is the priority. (Option D) Blood in the urine can be a symptom of low platelets due to lack of clotting ability. Although this is concerning, alterations in level of consciousness is the priority. Educational objective: A priority assessment in a client with low platelets is any change in level of consciousness (eg, disorientation, lethargy, restlessness). This can indicate intracranial bleeding and increased intracranial pressure.

Question 8

A client is admitted to the medical surgical floor with a hemoglobin level of 5.0 g/dL (50 g/L). The nurse should anticipate which findings? Select all that apply.

Accepted Answer

A normal hemoglobin level for an adult male is 13.2-17.3 g/dL (132-173 g/L) and female is 11.7-15.5 g/dL (117-155 g/L). A client with severe anemia will have tachycardia, which will maintain cardiac output. The cardiovascular system must increase the heart rate and stroke volume to achieve adequate perfusion. Shortness of breath (dyspnea) may occur due to an insufficient number of red blood cells. The respiratory system must increase the respiratory rate to maintain adequate levels of oxygen and carbon dioxide. Pallor (pale complexion) occurs from reduced blood flow to the skin. (Option A) Coarse crackles occur with fluid overload but not with anemia. (Option D) Respiratory depression does not occur with anemia. Respiratory depression may occur post-administration of a narcotic or during oversedation. Educational objective: Cardiac and respiratory drive is increased to maintain cardiac output and oxygenation in the setting of anemia.

Question 9

A home health nurse is visiting a client who underwent right-sided mastectomy with lymph node removal. The client is concerned about swelling in her arm on the affected side. Which instructions should the nurse discuss with the client? Select all that apply.

Accepted Answer

Lymphedema is the accumulation of lymph fluid in the soft tissue. It can occur as a result of lymph node removal or radiation treatment. When the axillary nodes cannot return lymph fluid to central circulation, the fluid can accumulate in the arm, hand, or breast. The client's arm may feel heavy or painful, and motor function may be impaired. The presence of lymphedema increases the client's risk for infection or injury of the affected limb. Interventions to manage lymphedema include: Decongestive therapy (massage technique to mobilize fluid) Compression sleeves or intermittent pneumatic compression sleeve (Option E) Compression sleeves are graduated with increased distal pressure and less proximal pressure. Clothing should also be less constrictive at the proximal arm and over the chest. Elevation of arm above the heart (Option C) Isometric exercises (Option D) Avoidance of venipunctures (eg, IV catheter insertion, blood draw), blood pressure measurements, and injections (eg, vaccinations) on the affected limb (Option B) Injury prevention (limb less sensitive to temperature changes) Infection prevention (limb more prone to infection through skin breaks) (Option A) Clients often learn massage techniques (ie, decongestive therapy) from physical therapists to increase lymphatic drainage and promote circulation of the extremity. Educational objective: Management for lymphedema includes decongestive massage therapy, compression bandages or sleeves, elevation of the arm above heart level, isometric exercises, and avoidance of venipuncture or blood pressure measurements on the affected limb.

Question 10

The nurse is caring for a 50-year-old client in the clinic. The client's annual physical examination revealed a hemoglobin value of 10 g/dL (100 g/L) compared to 13 g/dL (130 g/L) a year ago. What should be the nurse's initial action?

Accepted Answer

Early signs of colorectal cancer are usually nonspecific and include fatigue, weight loss, anemia, and occult gastrointestinal bleeding. Clients should have regular screening colonoscopy for colon cancer starting at age 50 if their risk is average or earlier if their risk is high. Colorectal screening can also include fecal occult blood test or fecal immunochemical test annually. New-onset anemia should be taken seriously at this client's age, and colon cancer must be ruled out. The etiology of anemia must be determined prior to recommending treatment. (Options A and B) The cause of anemia must be determined before recommendations can be provided for iron deficiency. There are many causes of anemia (including pernicious anemia) in older adults that involve deficiencies in vitamin B₁₂, not iron. (Option D) Waiting for 6 months will delay care. Educational objective: The etiology of new-onset anemia in an adult should be determined prior to treatment. Clients age ≥50 should be screened for colorectal cancer. Early signs include anemia.

Question 11

The nurse is caring for a client with severe chronic obstructive pulmonary disease (COPD).  The nurse anticipates which laboratory results for this client?

Accepted Answer

11ecbb05_c9d1_c047_b433_43802a1dd6b9_MD0009_00 The client with severe COPD will have a chronically low oxygen level, hypoxemia. To compensate, the body produces more red blood cells (RBCs) to carry needed oxygen to the cells. A high RBC count is called polycythemia. (Option A) Anemia is not expected and will worsen symptoms of COPD. (Option B) Neutropenia (low white blood cell count) is not expected in COPD. Chemotherapy and many medications (clozapine [antipsychotic], methimazole [antithyroid]) can cause neutropenia which increases the risk of infection. (Option D) Thrombocytopenia (low platelet count) is not anticipated in COPD. Alcohol use, HIV infection, and many medications (heparin) can cause thrombocytopenia. Educational objective: Polycythemia, an increase in RBCs, is an anticipated compensatory response to chronically low blood oxygen levels in clients with severe COPD.

Question 12

The nurse teaches a client diagnosed with iron-deficiency anemia about iron-rich foods.  Which meal does the client choose to indicate that teaching has been effective?

Accepted Answer

Iron-deficiency anemia occurs when the body lacks sufficient iron to form red blood cells and synthesize hemoglobin. Iron-deficiency anemia can result from: Diets low in iron (eg, vegetarian and low-protein diets)Iron not being absorbed (eg, following many gastrointestinal [GI] surgeries, malabsorption syndrome)Increased iron requirement (eg, children's growth spurts, pregnancy, breastfeeding)Blood loss (eg, menstruation, bleeding in the GI tract [eg, ulcers, hemorrhoids]) Diets low in iron (eg, vegetarian and low-protein diets) Iron not being absorbed (eg, following many gastrointestinal [GI] surgeries, malabsorption syndrome) Increased iron requirement (eg, children's growth spurts, pregnancy, breastfeeding) Blood loss (eg, menstruation, bleeding in the GI tract [eg, ulcers, hemorrhoids]) Foods rich in iron include: Meats (eg, beef, lamb, liver, chicken, pork)Shellfish (eg, oysters, clams, shrimp)Eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, and oatmeal Meats (eg, beef, lamb, liver, chicken, pork) Shellfish (eg, oysters, clams, shrimp) Eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, and oatmeal Eating foods rich in vitamin C (eg, citrus fruits, potatoes, tomatoes, green vegetables) with iron-rich foods will enhance iron absorption but coffee and tea consumption interferes with this process. (Option A) Chicken in a salad is a good source of iron. However, bread, pudding, and milk do not contain significant amounts of iron. (Option B) Fat-free yogurt, carrot sticks, apple slices, and diet soda do not offer a significant source of iron. (Option C) Ham is a good source of iron. However, carrots, green beans, and gelatin desserts are not significant sources. Furthermore, the tea will inhibit iron absorption. Educational objective: Clients with iron-deficiency anemia should be taught to eat iron-rich foods such as meats (eg, beef, lamb, liver, chicken, pork), shellfish (eg, oysters, clams, shrimp), eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, and oatmeal.

Question 13

After receiving report, which client should the nurse assess first?

Accepted Answer

Thrombocytopenia is a serious complication of heparin products (eg, unfractionated heparin and low-molecular-weight heparin [eg, enoxaparin]). Regardless of its cause, thrombocytopenia usually results in bleeding complications. However, in heparin-induced thrombocytopenia (HIT) this usually leads to paradoxical venous and/or arterial thrombosis and less commonly to bleeding. The mechanism for thrombosis is unclear. The danger of HIT is risk of organ damage from local thrombi and/or embolization, leading to stroke and/or pulmonary embolism. HIT occurs over several days. The nurse should monitor platelet levels of clients on heparin and report a decrease of ≥50% from baseline or a drop below 150,000/mm³ (150 x 10⁹/L) to the health care provider. If the client has HIT, all heparin products must be stopped immediately, and a different anticoagulant (eg, argatroban) should be started to prevent thrombosis risk. (Option B) This client with mildly elevated blood urea nitrogen (normal 6-20 mg/dL [2.1-7.1 mmol/L]) needs IV fluids. This is not the priority. (Option C) The client with myelodysplastic syndrome does not produce adequate blood cells. Low white blood cell count, platelets, and hemoglobin are expected. Although this client is at risk for infection, HIT has a higher priority. (Option D) Decreased hemoglobin and hematocrit are expected in sickle cell disease due to chronic/acute hemolysis. A packed red blood cell transfusion may be needed, but this is not the priority. Educational objective: Drug-induced thrombocytopenia may result in bleeding; however, heparin-induced thrombocytopenia has an added risk of thrombosis. The nurse should monitor platelet levels of clients on heparin and report a decrease of ≥50% from baseline or a drop below 150,000/mm³ (150 x 10⁹/L) to the health care provider.

Question 14

The nurse is teaching about cervical cancer prevention during a women's health conference. Which of the following factors should be taught as risks for cervical cancer? Select all that apply.

Accepted Answer

11ecbb05_c9d0_aed6_b433_b52941b3737f_MD0009_00 Almost all cases of cervical cancer result from persistent infection due to human papillomavirus (HPV), a primary risk factor (Option B). HPV is the most common sexually transmitted infection but is usually transient and resolves spontaneously. However, persistent HPV infection can cause abnormal changes in cervical epithelial tissue that slowly progress to invasive cancer if not treated. Most other risk factors for cervical cancer are related to behaviors that increase the client's risk of contracting HPV or an inability to clear the infection. Clients who have multiple sexual partners or initiate sexual activity at an early age (<18) increase their risk for exposure to HPV (Options C and E). Clients with weakened immunity (eg, HIV, immunosuppressive therapy) may have an impaired ability to clear HPV, which increases the risk for cervical cancer due to persistent infection (Option A). (Option D) Nulliparity (ie, no previous pregnancies) is not a risk factor for cervical cancer; however, it is a risk factor for breast cancer. Educational objective: Human papillomavirus is the most common sexually transmitted infection and is a primary risk factor for cervical cancer. Other cervical cancer risk factors include sexual activity at an early age (age <18), multiple sexual partners, and weakened immune system function (eg, HIV infection).

Question 15

A client with polycythemia vera comes to the clinic for a monthly treatment.  The nurse knows that treatment for this condition will consist of which of the following?

Accepted Answer

Polycythemia vera (PV) is a chronic myeloproliferative disorder in which the bone marrow produces an abnormally high number of RBCs. Although PV is an abnormality of the bone marrow, secondary polycythemia can occur in an individual with chronic hypoxemia, such as chronic obstructive pulmonary disease or chronic lung disease. The danger of PV is seen when the client develops blood clots-due to the increased viscosity of the blood, which makes the circulation sluggish-and decreased tissue perfusion. Treatment of PV usually includes periodic phlebotomy, the removal of 300-500 mL of blood through venipuncture, to reduce the RBC count and achieve a hematocrit <45%. Initially, clients may require phlebotomy every other day until the goal hematocrit is reached. Hematocrit is then monitored monthly, and additional blood draws are performed as necessary. (Option A) A blood transfusion is contraindicated in a client with PV because this would have the opposite of the desired effect, further increasing the RBC count and clotting. (Option B) Although an IV fluid bolus may be helpful in the short term to reduce blood viscosity, it is not a maintenance treatment for PV. Instead, the client should be encouraged to drink >3 L of fluid daily and avoid dehydration. (Option D) Steroid injections are not typically used to treat PV. Educational objective: A client with polycythemia vera requires periodic therapeutic phlebotomy treatments to reduce the RBC count and risk of blood clotting associated with increased blood viscosity.

Question 16

The nurse assesses a client 5 minutes after initiating a blood transfusion. The client has shortness of breath, itching, and chills. The nurse immediately turns off the transfusion and disconnects the tubing at the catheter hub. What action should the nurse take next?

Accepted Answer

Signs of a transfusion reaction include chills, fever, low back pain, flushing, and itching. Nursing interventions include: Stop transfusion immediately and disconnect tubing at the catheter hub.Maintain IV access with normal saline, using new tubing to prevent hypotension and vascular collapse (Option B).Notify health care provider (HCP) and blood bank.Monitor vital signs.Recheck labels, numbers, and the client's blood type.Treat client's symptoms according to the HCP's prescription.Collect blood and urine specimens to evaluate for hemolysis.Return blood and tubing set to the blood bank for additional testing.Complete necessary facility paperwork to document the reaction. Stop transfusion immediately and disconnect tubing at the catheter hub. Maintain IV access with normal saline, using new tubing to prevent hypotension and vascular collapse (Option B). Notify health care provider (HCP) and blood bank. Monitor vital signs. Recheck labels, numbers, and the client's blood type. Treat client's symptoms according to the HCP's prescription. Collect blood and urine specimens to evaluate for hemolysis. Return blood and tubing set to the blood bank for additional testing. Complete necessary facility paperwork to document the reaction. (Option A) Monitoring vital signs would be the step after ensuring IV access, administering normal saline, and notifying the HCP. (Option C) The nurse should ensure continued IV access before notifying the HCP. The HCP will likely prescribe IV medications (eg, vasopressors, antihistamines, corticosteroids) to treat the transfusion reaction, so a patent IV is critical. (Option D) Mislabeling blood and administering the wrong blood type are the most common causes of a transfusion reaction. However, maintaining IV access takes priority over investigating a potential clinical error. Educational objective: During a blood transfusion reaction, the nurse should immediately stop the transfusion and initiate normal saline to maintain IV access and prevent hypotension and vascular collapse.

Question 17

The nurse is caring for a client with hemophilia admitted for a facial laceration and hemarthrosis of the left knee after falling at home. Which of the following actions by the nurse are appropriate? Select all that apply.

Accepted Answer

Hemophilia is a group of disorders characterized by deficiencies in production or use of coagulation proteins (eg, factor VIII, factor IX), resulting in impaired clot formation and increased risk for uncontrolled bleeding. Hemophilia is typically identified by prolonged or excessive bleeding, severe bruising, or joint bleeding (ie, hemarthrosis) after injuries or procedures. Administration of supplemental IV clotting factors (eg, factor VIII, factor IX) is the primary treatment for acute bleeding in clients with hemophilia (Option A). Clients with hemophilia have increased risk of hemarthrosis (ie, bleeding in joint). In addition to administration of IV clotting factors, hemarthrosis is managed with rest, ice, compression, and elevation (RICE). Application of ice or cold packs promotes local vasoconstriction and clot formation (Option C). The affected joint should be maintained in the extended position to prevent flexion contracture (Option D). Frequent neurologic assessments are required for clients with hemophilia who have suspected (facial laceration in this client) or confirmed head trauma, as neurologic alteration may indicate intracranial bleeding (Option E). (Option B) When caring for clients with hemophilia, the nurse should eliminate factors that increase bleeding risk or promote complications from bleeding. NSAIDs (eg, aspirin, ibuprofen) are avoided as they inhibit platelet aggregation, which increases bleeding risk Educational objective: For acute bleeding, clients with hemophilia are treated with supplemental IV clotting factors. Hemarthrosis is managed with rest, ice, compression, and elevation, and the affected joint should remain extended to prevent contractures. NSAIDs (eg, ibuprofen) increase bleeding risk and should be avoided for clients with hemophilia.

Question 18

A client has potential radiation contamination from a disaster. The nurse should monitor for which of the following related to this contamination? Select all that apply.

Accepted Answer

Radiation damages the DNA, which causes cell destruction. Radiation (and chemotherapy) usually affects tissues with rapidly proliferating cells (eg, oral mucosa, gastrointestinal tract, bone marrow) first, followed by tissues with slowly proliferating cells (eg, cartilage, bone, kidney). As a result, early manifestations of radiation damage include oral mucosal ulcerations, vomiting/diarrhea, and low blood cell counts. The extent of radiation exposure can be monitored indirectly by measuring blood cell counts. (Option A) A bitter almond smell on the client's breath is a classic sign of cyanide poisoning. (Option B) Fever and raised skin pustules are signs/symptoms of smallpox, which is transmitted from person to person via respiratory droplets. Infection starts with fever, followed by a rash and then sharply raised pustules. Educational objective: Radiation contamination (and chemotherapy) affects rapidly proliferating (dividing) cells first, such as those of the oral mucosa, gastrointestinal tract, and bone marrow.

Question 19

The nurse plans discharge teaching for a client newly diagnosed with polycythemia vera. Which actions will the nurse include in the teaching plan? Select all that apply.

Accepted Answer

Polycythemia vera (PV) is a chronic disorder of the bone marrow in which too many red blood cells, white cells, and platelets are produced. Clients with PV are at risk of developing blood clots due to increased blood volume and viscosity. Clients are instructed to elevate the legs and feet when sitting, wear support stockings, and report signs of thrombosis (eg, swelling and tenderness in the legs). Adequate fluid intake during exercise and hot weather is important to reduce fluid loss and decrease viscosity (Options A, C, and E). (Option B) Increasing intake of iron-containing foods and supplements can further increase hemoglobin production and is not recommended. Clients with PV need periodic phlebotomy to remove excess blood. (Option D) Itching is a common and frustrating symptom of PV. Reducing water temperature, using starch baths, and patting the skin dry rather than rubbing vigorously are beneficial. Educational objective: Clients with polycythemia vera are at risk of developing thrombosis and should be taught preventive measures (eg, elevating the legs when sitting) and symptoms to report. They should take measures to prevent dehydration, and avoid iron-rich foods and hot showers/baths.

Question 20

Which client finding is most important for the nurse to follow up?

Accepted Answer

Purpura refers to reddish-purple blotches on the skin that do not blanch with pressure due to bleeding underneath the skin. Further assessment must be done to evaluate for a potentially serious etiology, such as blood dyscrasia. (Option A) The normal finding is a soft, distinct liver edge that is even with the bottom of the right rib cage or right costal margin. An abnormal finding would be a boggy liver edge below the rib cage (hepatomegaly). (Option B) Kidney inflammation (pyelonephritis) results in positive costovertebral angle (CVA) tenderness tenderness in the back/flank. It is an expected finding that is elicited when the examiner places the hand over the client's lower back and places the other hand on top and makes a fist to gently "thump" or tap the area. (Option D) The Babinski sign can indicate an upper motor neuron lesion from damage to the corticospinal tract. A normal finding for an adult is for the toes to point downward. Educational objective: Purpura refers to purplish blotches indicating bleeding underneath the skin; it is a significant finding that requires further assessment.

Exam 1: Adult Health

The nurse provides care for a client diagnosed with polycythemia vera. Which statement by the client would require immediate follow-up?

The nurse is admitting a client who had mastectomy 6 months ago and is scheduled for elective surgery. During the physical assessment, the nurse notices a 0.5 cm mobile, firm, nontender lymph node in the upper arm. What action should the nurse take?

The nurse provides home care education to a client newly diagnosed with von Willebrand disease. Which of the following client statements demonstrate correct understanding of the education? Select all that apply.

A client on a medical-surgical unit is receiving heparin therapy. Platelet levels decreased from 230,000/mm³ (230 × 10⁹/L) 2 days ago to 80,000/mm³ (80 × 10⁹/L) today. Which nursing actions are appropriate? Select all that apply.

The nurse receives report on the assigned team of clients on the oncology unit. All are receiving chemotherapy. Which client should the nurse check on first?

A nurse is caring for a client 1 day after a left-sided mastectomy with lymph node dissection. Which nursing intervention is the priority in caring for this client?

Thrombotic thrombocytopenic purpura is suspected due to the client's current platelet count of 2,000/mm³ (2 x 10⁹/L) . Which client sign or symptom is the most concerning and requires immediate further nursing action?

A client is admitted to the medical surgical floor with a hemoglobin level of 5.0 g/dL (50 g/L) . The nurse should anticipate which findings? Select all that apply.

A home health nurse is visiting a client who underwent right-sided mastectomy with lymph node removal. The client is concerned about swelling in her arm on the affected side. Which instructions should the nurse discuss with the client? Select all that apply.

The nurse is caring for a 50-year-old client in the clinic. The client's annual physical examination revealed a hemoglobin value of 10 g/dL (100 g/L) compared to 13 g/dL (130 g/L) a year ago. What should be the nurse's initial action?

The nurse is caring for a client with severe chronic obstructive pulmonary disease (COPD) . The nurse anticipates which laboratory results for this client?

The nurse teaches a client diagnosed with iron-deficiency anemia about iron-rich foods. Which meal does the client choose to indicate that teaching has been effective?

After receiving report, which client should the nurse assess first?

The nurse is teaching about cervical cancer prevention during a women's health conference. Which of the following factors should be taught as risks for cervical cancer? Select all that apply.

A client with polycythemia vera comes to the clinic for a monthly treatment. The nurse knows that treatment for this condition will consist of which of the following?

The nurse assesses a client 5 minutes after initiating a blood transfusion. The client has shortness of breath, itching, and chills. The nurse immediately turns off the transfusion and disconnects the tubing at the catheter hub. What action should the nurse take next?

The nurse is caring for a client with hemophilia admitted for a facial laceration and hemarthrosis of the left knee after falling at home. Which of the following actions by the nurse are appropriate? Select all that apply.

A client has potential radiation contamination from a disaster. The nurse should monitor for which of the following related to this contamination? Select all that apply.

The nurse plans discharge teaching for a client newly diagnosed with polycythemia vera. Which actions will the nurse include in the teaching plan? Select all that apply.

Which client finding is most important for the nurse to follow up?