paaspoint Immune and Hematologic Disorders
A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?
"I will receive parenteral vitamin B12 therapy for the rest of my life." Explanation: Because a client with pernicious anemia lacks intrinsic factor, oral vitamin B12 can't be absorbed. Therefore, parenteral vitamin B12 therapy is recommended and required for life.
The parents of an infant report they are concerned about giving their child immunizations due to their association with autism. Which response by the nurse is appropriate?
"Studies do not support a link between autism and immunizations." Explanation: There has been a great deal of discussion about the risk of autism being increased with the administration of immunizations. Studies do not presently show a correlation regardless of whether they are live or inactivated vaccines.
A parent asks the clinic nurse how often the influenza virus vaccine should be given to a child. Which response would be most accurate?
"The vaccine is usually given annually to children with certain risk factors." Explanation: The influenza virus vaccine is usually administered annually to children at risk, not at monthly or 6-month intervals. The vaccine isn't contraindicated in children but is targeted at clients with chronic cardiac, pulmonary, hematologic, and neurologic problems.
A multidisciplinary oncology team of physicians, nurses, and the social worker notes that a client who has been undergoing chemotherapy is now experiencing pancytopenia. When reviewing the laboratory data, which values support this diagnosis? Select all that apply. -decreased white blood cells -increased white blood cells -decreased platelets -increased platelets -decreased red blood cells -increased red blood cells
-decreased white blood cells -decreased platelets -decreased red blood cells
The nurse is working in the emergency department when a child is admitted in sickle cell crisis. Which interventions should the nurse expect to perform? Select all that apply. give blood transfusions -give antibiotics -increase fluid intake -administer prescribed analgesics -prepare the child for a splenectomy
-increase fluid intake -administer prescribed analgesics
After undergoing testing, a client comes to a physician's office for a follow-up appointment. During the appointment, the physician informs the client that she has systemic lupus erythematosus (SLE). Which resource might be helpful for a nurse to recommend to this client?
A support group for clients with SLE Explanation: The nurse should recommend that the client attend a support group for clients with SLE. This group should be able to provide the client with information and resources that can help her cope with her diagnosis. The physician must prescribe occupational therapy if needed. A social worker consult is only necessary if the client is unable to provide for her own financial needs, but nothing suggests that this client has financial needs. Home health care must be prescribed by the physician, but nothing suggests that the client requires home health care at this time.
How can a nurse best protect herself after she experiences a minor allergic reaction to latex?
Avoid use of all latex products. Explanation: After experiencing a latex allergy of any magnitude, the nurse must protect herself by avoiding all latex products. An allergic reaction kit won't prevent an allergic reaction from occurring.
A nurse is assigned to a client experiencing Stage 3 hypovolemic shock. Which findings should the nurse expect to notice?
BP 87/58 mm Hg, HR 123, urine output of 20 ml/hour, clammy skin Explanation: Signs and symptoms of hypovolemic shock would include change in the level of consciousness; cool, clammy, and pale skin; hypotension; tachycardia; and tachypnea. The client will also have oliguria or decreased urine output because of decreased circulation of fluid volume. The normal urine output is between 30 to 50 ml/hour.
A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change?
Bluish urine Explanation: Lymphangiography may turn the urine blue temporarily; it doesn't alter stool color. For several months after the procedure, the upper part of the feet may appear blue, not red. Lymphangiography doesn't affect the soles.
A client arrives at the emergency department reporting chest and stomach pain and a history of black, tarry stools for the past 2 months. Which orders should the nurse anticipate?
ECG, complete blood count, testing for occult blood, and comprehensive serum metabolic panel
Which action must a nurse take first before drawing a blood sample for human immunodeficiency virus (HIV) testing?
Make sure that an informed consent form has been signed. Explanation: Before obtaining a sample for HIV testing, the nurse should make sure that an informed consent form has been signed. The nurse should explain why she is obtaining the sample — in this case, for HIV testing, not for routine testing. Gloves are necessary to obtain the sample. Eye protection should also be worn if splashing is likely. The client should be informed of the test results whether they are positive or negative.
The physician prescribes didanosine (ddI), 200 mg by mouth every 12 hours, for a client with acquired immunodeficiency syndrome (AIDS) who is intolerant to zidovudine (azidothymidine, AZT). Which condition in the client's history warrants cautious use of this drug?
Peripheral neuropathy Explanation: A history of peripheral neuropathy, renal or hepatic impairment, hyperuricemia, or pancreatitis warrants cautious use of didanosine because these disorders increase the risk of adverse effects. Diabetes mellitus, hypertension, and asthma aren't significant history findings for a client who is to receive didanosine.
The nurse is caring for a child who is receiving steroid therapy as a part of the cancer treatment plan. The child tearfully asks the nurse," Why does my face looks so "fat?" What information should be included in the nurse's response?
This change is temporary and will subside once the steroid medication has been discontinued. Explanation: Steroid therapy is associated with an increased roundness of the face. This may be a source of distress to the child and parents. It is important to explain that this is the result of the medication therapy and will subside.
A client with blood type B needs a blood transfusion. Which type of blood can this client receive?
Type B or type O blood Explanation: Type B blood contains B antigens and anti-A antibodies, but no anti-B antibodies. Therefore, a client with type B blood can receive type B or type O blood (which contains neither anti-A nor anti-B antibodies).
A nurse is caring for several client's with human immunodeficiency virus (HIV) infection. Which client does the nurse suspect has acquired immunodeficiency syndrome (AIDS) wasting syndrome?
a client who has lost 12% of her body weight, with weakness, fever, and chronic diarrhea for the past 35 days Explanation: AIDS wasting syndrome is diagnosed when there's a loss of 10% or more of body weight and the presence of one or more of the following for more than 30 days: fever, weakness, and at least two loose stools daily. Oral pain with visible yellow-white plaques and vaginitis with a white, cottage cheese-like discharge suggest infection with Candida albicans. Impaired intellect and motor functioning indicate HIV infection of the central nervous system with AIDS dementia complex.
A client is placed on neutropenic precaution. Which nursing action is appropriate?
avoiding yogurt for breakfast Explanation: Yogurt and yogurt products should be avoided because they have live and active cultures, which may predispose a client with low white blood cells (WBC) to infection.
A client takes prednisone, as prescribed, for rheumatoid arthritis. The nurse should tell the client to look for common adverse reactions to this drug, such as:
fluid retention and weight gain. Explanation: Common adverse reactions to prednisone and other steroids include sodium retention, fluid retention, and weight gain. Tetany and tremors are occasional adverse reactions to certain other drugs. Anorexia, abdominal cramps, and diarrhea are common adverse reactions to many drugs, but not to steroids. Flatus isn't an adverse effect associated with steroid therapy.
A client is receiving the drug epoetin alfa. Which findings would indicate the effectiveness of the drug?
increase in red blood cells Explanation: Epoetin alfa is a synthetic form of protein human erythropoietin. It stimulates the bone marrow to produce more red blood cells (RBC). The drug is used to treat anemia caused by chronic kidney disease, chemotherapy, and zidovudine (AZT), which is a drug used to treat HIV infection.
During the admission process, the nurse evaluates a client with rheumatoid arthritis. To assess for the most obvious disease manifestations first, the nurse checks for:
joint abnormalities. Explanation: Joint abnormalities are the most obvious manifestations of rheumatoid arthritis. A systemic disease, rheumatoid arthritis attacks all connective tissue. Nonarticular connective tissue, such as collagen in the lungs, heart, muscles, vessels, pleura, and tendons, may be involved diffusely. Vasculitis may affect the eyes, nervous system, and skin, causing thrombosis and ischemia. Although muscle weakness may occur from limited use of the joint where the muscle attaches, such weakness isn't the most obvious sign of rheumatoid arthritis; also, it occurs only after joint abnormalities arise. Subcutaneous nodules, although common in rheumatoid arthritis, are painless. The disease may cause gait disturbances, but these follow joint abnormalities.
A client is injected with radiographic contrast medium and immediately shows signs of dyspnea, flushing, and pruritus. Which intervention should take priority?
make sure the airway is patent
A client is diagnosed with von Willebrand disease. Where should the nurse most closely monitor for bleeding?
mucous membranes Explanation: The most characteristic clinical feature of von Willebrand disease is an increased tendency to bleed from mucous membranes, which may be seen as frequent nosebleeds or menorrhagia. In hemophilia, the joint cavities are the most common site of internal bleeding. Bleeding into the GI tract, spinal cord, and brain tissue can occur, but these are not the most common sites for bleeding.
The nurse is caring for a child who has just been diagnosed with sickle cell anemia. Which initial action will be most therapeutic?
offer emotional support Explanation: The nurse can be instrumental in providing support, encouragement, and correct information to the parents of a child newly diagnosed with sickle cell anemia. Selective birth methods, such as in vitro fertilization of an embryo without markers for sickle cell disease, are discussed, but parents make their own decisions. All heterozygous, or trait-positive, parents should be referred for genetic counseling. The risk of transmission of sickle cell anemia in subsequent pregnancies remains the same.
A child is seeing the health care provider for bone and joint pain. Which other signs and symptoms may suggest leukemia?
petechiae Explanation: The most common signs and symptoms of leukemia result from infiltration of the bone marrow. These include petechiae, fever, pallor, and joint pain with decreased activity level. Abdominal pain is caused by areas of inflammation from normal flora in the GI tract. Increased appetite can occur, but it usually isn't a presenting symptom.
A nurse is caring for a client newly diagnosed with Human Immunodeficiency Virus (HIV). Which action by the nurse violates the client's confidentiality?
sharing the client's information with the clergy who is visiting with the client Explanation: The clergy has no direct involvement in the care of the client and therefore should have no knowledge of the client's information. Sharing client's information with anyone who is not directly involved with the care of the client violates confidentiality. Family members can only have access to client information after the client has authorized the health care agency to release such information. The nursing assistant who is caring for the client needs to know the client's status.
The nurse is meeting with a client who has recently been diagnosed with human immunodeficiency virus (HIV). The client is concerned about the impact of sharing the recent diagnosis with friends and family. What information can the nurse provide to the client?
sharing the diagnosis with friends and family members will provide a needed source of support Explanation: Studies support the benefit of sharing an HIV positive status with friends and family. This provides a source of support for the individual. Feelings of isolation may be heightened when the individual feels forced to live a double life and hide the truth of his HIV status. While the diagnosis of HIV may be difficult for friends and family to hear, it will allow them the opportunity of having increased openness and honesty in the relationship.
A nurse applies standard precautions when caring for a client with human immunodeficiency virus (HIV). The nurse takes what action when applying standard precautions?
wearing gloves for providing mouth care Explanation: The client's HIV status is irrelevant to the application of standard precautions, and the client should not be treated differently because of this diagnosis. A healthcare worker wears gloves when contact with any client's blood or body fluids is anticipated, such as when providing mouth care. Such barrier protection helps prevent viruses from entering the bloodstream. When assisting a client to get dressed, gloves are not required unless contact with blood is anticipated. Gowns are not required for intravenous insertion, and a dedicated commode is not part of standard precautions.
The nurse is reinforcing education to the parents of a child with leukemia about the three main consequences. What should the nurse inform the parents they should monitor for?
anemia, infection, and bleeding tendencies Explanation: The three main consequences of leukemia are anemia, caused by decreased erythrocyte production; infection secondary to neutropenia; and bleeding tendencies from decreased platelet production. Bone deformities don't occur with leukemia, although bones may become painful because of the proliferation of cells in the bone marrow. Spherocytosis refers to erythrocytes taking on a spheroid shape and isn't a feature of leukemia. Hirsutism and growth delay can be a result of large doses of steroids but aren't common in leukemia. Anemia, not polycythemia, occurs. Clotting times would be prolonged.
A nurse is reinforcing discharge instructions for a client with systemic lupus erythematosus (SLE). Which intervention is most important for the nurse to include?
apply sunscreens with SPF higher than 15 daily Explanation: Clients with SLE have photosensitivity to sunlight and should wear SPF 15 or higher sunscreen daily, protective clothing, and/or avoid sun exposure to limit photosensitive rash or disease flares. Fluid restrictions, checking blood sugar and avoiding foods containing peanuts is not necessary for clients with SLE.
A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement made by the client about safer sex practices for persons with HIV is accurate?
"A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse." Explanation: A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse. The nurse should caution the client not to have unprotected sex because continued exposure to HIV in a seropositive client may hasten the course of the disease or result in infection with another strain of HIV. Hormonal contraceptives, implants, and injections offer no protection against HIV transmission. Safe sex practices include hugging, petting, mutual masturbation, and protected sexual intercourse. Abstinence is the most effective way to prevent transmission.
A nurse is reinforcing nutritional counseling to the parent of a child with celiac disease. Which statement by the parent indicates understanding of the diet?
"I need to read food labels carefully to avoid gluten additives in foods." Explanation: A child with celiac disease must eat a gluten-free diet. If foods containing gluten are eaten, changes occur in the intestinal mucosa that prevent the absorption of nutrients, especially fats. Therefore, all foods containing wheat, rye, oats, and barley must be eliminated from the diet. It is important to read food labels to monitor for hidden glutens. Such foods as potatoes, rice, flour, and cornstarch are allowed in a gluten-free diet. Frozen and packaged foods may contain gluten fillers; therefore, they should be avoided.
A staff member on the transplant unit is having problems logging into the computer to chart client information. The staff member asks a nurse for their personal identification number (PIN) to log in. What is the nurse's best response?
"I'll be happy to contact Information Services to assist you with the problem." Explanation: By telling the staff member that nurse will contact Information Services, the nurse is providing support and help without disclosing private information. Although telling the staff member that the request is inappropriate maintains confidentiality and security, this response may create interpersonal tension. Sharing a PIN or allowing someone to chart under another person's name may inadvertently put confidential client information at risk.
A client presents to the emergency department with flu-like symptoms. During data collection, the nurses note the client returned from vacation 3 weeks ago, had a blood transfusion 3 years ago, and the sclera appears yellow in color. After being diagnosed with Hepatitis A virus (HAV), the client states, "How could I have gotten hepatitis?" Which nursing response given is most accurate?
"It may have happened if the food handler in a restaurant had the virus." Explanation: HAV is spread by the oral-fecal route and is transmitted through contaminated water, food, food handlers, or oral-anal sex. Hepatitis B, C, and D are transmitted through blood. Toxic hepatitis is transmitted by inhalation of chemicals. Hepatitis B and C are transmitted via unprotected sex.
The parents of a child diagnosed with leukemia have stated that they'll give aspirin to their child for pain relief. Which statement by the nurse about aspirin would be most accurate?
"It's contraindicated because it promotes bleeding tendencies." Explanation: Aspirin would be contraindicated be cause it promotes bleeding. Aspirin use has also been associated with Reye syndrome in children. For home use, acetaminophen is recommended for mild to moderate pain. Aspirin enhances the effects of methotrexate and has no effect on platelet production. Non opioid analgesia has been effective for mild to moderate pain in children with leukemia.
The nurse is caring for a client with pernicious anemia. Which question by the nurse explains the potential source of the anemia?
"What type of diet do you follow?" Explanation: The use of a vegan diet can lead to pernicious anemia from not eating foods such as meat, poultry, shellfish, eggs, and dairy products that maintain B12 levels. Bladder surgery will not cause B12 absorption problems. Visual changes and medications have not been related to pernicious anemia.
The nurse is caring for a client who is scheduled to undergo a bone marrow aspiration to assess the progression of a hematologic disorder. Which interventions should the nurse include as part of the preprocedural teaching plan? Select all that apply. -explain the procedure to the client -maintain a pressure dressing over the aspiration site -encourage the client to ask questions before obtaining the signed informed consent -explain that the client will receive an analgesic prior to the procedure -administer an anxiety-relieving medication prior to the procedure -Instruct the client to save all voided urine for 24 hours after the procedure
-explain the procedure to the client -encourage the client to ask questions before obtaining the signed informed consent -explain that the client will receive an analgesic prior to the procedure The client should understand the procedure and the reason why it is necessary before signing an informed consent form. The client also should be advised of the local analgesia to be administered before the procedure begins. Although the client may receive an anxiety-relieving medication before the procedure, administering the drug is not part of the teaching plan. Likewise, maintaining pressure over the insertion site is a nursing intervention performed after the procedure; it is not a part of the preoperative teaching. Instructing the client to save voided urine would be part of the postprocedural discharge plan.
A nurse is reinforcing discharge instructions to a client after treatment for a severe allergic reaction from a bee sting. What instructions should the nurse include? Select all that apply. -fill the prescription for injectable epinephrine to carry with you -apply perfume liberally as a protection -dress in sleeveless, easily removable garments -obtain diphenhydramine to take following a bee sting -wear bright colors to repel insects
-fill the prescription for injectable epinephrine to carry with you -obtain diphenhydramine to take following a bee sting Explanation: An emergency kit with diphenhydramine and/or injectable epinephrine is recommended. Insects are attracted by bright colors and perfume. Arms and legs should be covered with clothing.
A client is admitted with hemophilia. Which sports should the nurse recommend for this client? Select all that apply. -basketball -swimming -baseball -golf -soccer
-swimming -golf Explanation: A client with hemophilia should avoid contact sports like soccer, baseball, and basketball because of the risk of bleeding with injury. The client can safely participate in noncontact sports such as swimming and golf.
A client reports nausea and vomiting as a side effect of radiation and chemotherapy. When is the best time for the nurse to administer antiemetics?
30 minutes before initiation of therapy. Explanation: Antiemetics are most beneficial if given before the onset of nausea and vomiting. To calculate the optimum time for administration, the first dose is given 30 minutes to 1 hour before nausea is expected, and then every 2, 4, or 6 hours for approximately 24 hours after chemotherapy. If the antiemetic were given with the medication or after the medication, it could lose its maximum effectiveness when needed.
The nurse is observing a client with cerebral edema for evidence of increasing intracranial pressure. The client's current blood pressure is 170/80 mm Hg. What's the client's pulse pressure? Record your answer using a whole number.
90 Explanation: Pulse pressure is the difference between the systolic blood pressure and the diastolic blood pressure.170 mm Hg - 80 mm Hg = 90 mm Hg.
A client's blood studies reveal a deficiency in all of the blood's formed elements. The physician suspects that the client's bone marrow is failing to generate enough new cells. Which disorder is most likely affecting this client?
Aplastic anemia Explanation: Aplastic anemia usually results from injury or destruction of stem cells in bone marrow or the bone marrow matrix, causing pancytopenia (anemia, granulocytopenia, and thrombocytopenia) and bone marrow hypoplasia (fatty bone marrow). In sickle cell anemia, a defective hemoglobin molecule (HbS) causes red blood cells (RBCs) to roughen and become sickle shaped and more fragile. Folic acid deficiency anemia results from a decreased level or lack of folate, a vitamin that's essential for RBC production and maturation. With iron deficiency anemia, an inadequate supply of iron for optimal formation of RBCs results in smaller cells.
A 33-year-old client who tested positive for the human immunodeficiency virus (HIV) is admitted to the medical unit with pancreatitis. A nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director, who says that the client is her neighbor's son. What should the nurse do to protect the client's right to privacy?
Inform the nurse director that she's violating the client's right to privacy and ask her to return the chart. Explanation: Under the Health Insurance Portability and Accountability Act (HIPAA)(Health Canada), personal health information may not be used for purposes not related to health care. The nurse director isn't providing health care to the client and shouldn't have access to the chart, regardless of the client's condition. The nurse director should be confronted and asked to return the client's chart. If she doesn't comply, the nurse should report the incident to her nurse-manager, who will report the infraction to the proper authorities. The staff nurse shouldn't report the incident to the medical director.
How can a nurse best ensure the safety of a client who has a latex allergy?
Make sure that the latex allergy is properly documented. Explanation: The nurse should make sure that she properly documents the client's allergy to latex according to facility policy. She should then follow facility protocol for ensuring a latex-free environment for the client. The nurse shouldn't rely solely on verbal communication to inform the staff of the client's latex allergy. The client should be taught to avoid latex-containing products; however, the staff shouldn't rely on the client to make sure she avoids latex products. A physician's order is required for medication use, but daily antihistamine administration isn't necessary with latex allergy.
Which factor is most important when planning care for a client with a bleeding disorder?
Prioritization Explanation: Prioritization is most important because it helps prevent treatment delays that might be life-threatening. Time management is also important because it helps the nurse provide care efficiently, but it doesn't take priority over prioritizing care. Delegation is a responsibility that exists within the context of time management. Verbal communication is also important but not as important as prioritizing client care.
When a nurse removes an I.V. from an client with acquired immunodeficiency syndrome (AIDS), blood splashes into the nurse's eyes. What should the nurse do next?
Rinse their eyes with water, report the incident, and go to Employee Health Explanation: Transmission of the AIDS virus can occur through contact with mucous membranes, so it's vital that the nurse immediately flush their eyes with water. The nurse should properly report and document the incident in an incident report and seek follow-up care with a medical professional. The nurse shouldn't record this incident on the client's care record. A nurse who fails to rinse their may allow viral transmission through contact with the mucous membranes.
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
Risk for injury Explanation: In a client with AIDS, central nervous system (CNS) deterioration can lead to AIDS-related dementia. This type of dementia impairs cognition and judgment, placing the client at risk for injury. Although Bathing or hygiene self-care deficit and Complicated grieving may be relevant in AIDS, these diagnoses don't take precedence in a client with AIDS-related dementia. Because CNS deterioration results from infection, Ineffective cerebral tissue perfusion isn't applicable.
A nurse is working with a support group for clients with human immunodeficiency virus (HIV). Which health promotion strategy should the nurse reinforce with the group?
Take antiretroviral medications as prescribed. Explanation: It is essential for HIV infected clients to remain adherent with their antiretroviral therapy (ART) to suppress viral load and reduce the risk of transmitting HIV. Adherence with ART will help HIV infected clients to maintain their health. Clients with HIV should use safer-sex practices to prevent transmission of HIV and other sexually transmitted infections. Although it is helpful if clients with AIDS avoid using recreational drugs and alcohol to avoid virus transmission, it is more important that IV drug users use clean needles and dispose of used needles. Whether a client with AIDS chooses to tell potential sex partners about the diagnosis is the client's decision, unless the client is required to do so by law.
Which aspect is most important for successful management of the child with Reye syndrome?
early diagnosis Explanation: Early diagnosis and therapy are essential because of the rapid, clinical course of the disease and its high mortality. Reye syndrome is associated with a viral illness, and antibiotic therapy isn't effective to prevent the initial progression of the illness. Isolation isn't necessary because the disease isn't communicable. Staging, although important to therapy, occurs after a differential diagnosis is made.
Which instructions should the nurse include when reinforcing education to the parents about caring for a child with chickenpox?
administer antipruritics as ordered Explanation: Chickenpox is highly pruritic. Preventing the child from scratching is necessary to prevent scarring and secondary infection caused by irritation of lesions. Antibiotics aren't usually used to treat chickenpox. Interaction with other children would be contraindicated due to the risk of disease transmission unless the other children have previously had chickenpox or have been immunized. Varicella-zoster immune globulin should be given to exposed children who are taking aspirin because of the possible risk of Reye syndrome.
Which type of leukemia with fast growing immature lymphocytes accounts for most cases of childhood leukemia?
acute lymphocytic leukemia (ALL) Explanation: The most common subtype, ALL, accounts for 75% to 80% of all childhood cases, with AML (myelocytic, myelogenous, or nonlymphocytic) comprising approximately 20%, and CML approximately 2%. CLL occurs in older clients; 90% of cases are persons older than age 50.
Which intervention does the nurse determine has the most impact in delaying the development of acquired immunodeficiency syndrome (AIDS) once a client has been infected with human immunodeficiency virus (HIV)?
adherence with the complete therapeutic regimen Explanation: Compliance with the complete therapeutic regimen includes adhering to a healthy lifestyle, taking prescribed medications, and reducing risks from other infections. This is the most important intervention in delaying the onset of AIDS. Eating a balanced diet and getting adequate rest and sleep are part of the overall therapeutic regimen. Plasmapheresis isn't a treatment for HIV/AIDS.
Following a kidney transplantation, a client is prescribed a combination of medications that includes steroids and cyclosporine. Which client education should the nurse reinforce?
avoid being in crowded places Explanation: The client should avoid situations in which infections can be transmitted because his ability to resist pathogens is diminished. Steroids impair the immune system and cyclosporine is given to suppress the immune response and decrease the chance of transplant organ rejection. Home-canned foods should be boiled for 20 minutes and inspected before being consumed, but generally pose no greater risk of infection than commercially canned foods. Steroids and cyclosporine aren't associated with bleeding tendencies and should never be stopped abruptly. Even mild febrile episodes should be reported immediately because the client's immune system is impaired, and taking medications such as acetaminophen could mask the presence of serious infections.
A nurse is caring for several clients on an oncology unit. Which client should the nurse see first?
client with a white blood cell count of 2000 µL Explanation: A white blood cell count of 2000 µL puts the client at risk for infection. The nurse would want to see this client first in order to reduce the transmission of bacteria and other organisms from working with other clients. The client on bed rest can wait and the other clients are stable.
A nurse is caring for a client with Hodgkin lymphoma. What signs and symptoms would the nurse obtaining data indicate involvement of the enlarged lymph nodes in the chest and neck?
cough, dysphagia, and stridor Explanation: Enlarged lymph nodes of the neck and upper chest can produce such symptoms as cough, dysphagia, and stridor, due to pressure and obstruction of the structures of the respiratory system and esophagus. Although fever, weight loss, night sweats, and malaise are also seen with Hodgkin lymphoma, these symptoms are not directly related to enlargement of neck and chest lymph nodes. Bone pain and jaundice may indicate bone and liver metastasis.
While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand?
diphenhydramine hydrochloride Explanation: A client who is allergic to bee stings should keep diphenhydramine on hand because its antihistamine action can prevent a severe allergic reaction. Pseudoephedrine is a decongestant, which is used to treat cold symptoms. Guaifenesin is an expectorant, which is used for coughs. Loperamide is an antidiarrheal agent.
A child with hemophilia is hospitalized with bleeding into the knee. Which action should the nurse take first?
elevate the affected part Explanation: Bleeding into the joints is the most common type of bleeding episode in the more severe hemophilia forms. Elevating the affected part and applying pressure and cold are indicated. The nurse should anticipate transfusing the missing clotting factor—not whole blood or plasma, which won't stop the bleeding promptly and may pose a risk of fluid overload. Active ROM exercises are contraindicated because they may cause more bleeding, injury, and pain.
A child with weakness in the legs and a history of influenza is admitted with a diagnosis of Guillain-Barre syndrome. Which symptom, indicative of a possible serious complication, would the nurse report immediately to the primary health care provider?
increased hoarseness Explanation: The most serious complication of Guillain-Barre syndrome is respiratory failure, which occurs as paralysis progresses to the thoracic area. Increased hoarseness may be a sign of impending respiratory distress. Tingling in the hands and weak muscle tone in the arms and legs commonly occur with Guillain-Barre syndrome. It is not necessary to immediately notify the charge nurse and primary care provider of these findings.
Which nursing action is most important to decrease the risk of postoperative complications in a child with sickle cell anemia?
increasing fluids Explanation: The main surgical risk from anesthesia is hypoxia; however, emotional stress, demands of wound healing, and the potential for infection can each increase the sickling phenomenon. Increased fluids are encouraged because keeping the child well-hydrated is most important for hemodilution to prevent sickling. Preparing the child psychologically to decrease fear minimizes undue emotional stress. Deep coughing is encouraged to promote pulmonary hygiene and prevent respiratory tract infection. Analgesics are used to control wound pain and to prevent abdominal splinting and decreased ventilation.
A client with human immunodeficiency virus (HIV) experiences frequent bouts of diarrhea. The nurse determines dietary teaching is effective when the client states which food to avoid?
milk Explanation: Clients with chronic diarrhea may develop intolerance to lactose, which may worsen the diarrhea. Although red licorice (the candy) may be eaten, black licorice (the herb) should be avoided, as it may interfere with medications, especially corticosteroids. Other foods that the client should avoid include fatty foods, other lactose-containing foods, caffeine, and sugar. Chicken soup and broiled meat may be consumed.
An anxious client is brought to the walk in clinic with difficulty breathing following a bee sting. Which of the following is the nurse's priority action?
monitor the client's airway Explanation: The initial priority action with any client having difficulty breathing is to assess and maintain the airway. All other actions may be completed following the assessment of the airway.
The nurse is reinforcing nutritional information with a client with a leukocyte (WBC) count of 2,500/µL (2.50 × 109/L). What food should the nurse instruct the client avoid?
raw carrot sticks Explanation: The normal leukocyte (WBC) count is 4.500/µL to 11,000/µL (4.50 × 109/L to 11.00 × 109/L). A WBC count of 2,500/µL (2.50 × 109/L) is low, making the client prone to infection. A low-bacteria diet is indicated, which excludes raw fruits and vegetables.
A nurse obtains data from a client receiving a blood transfusion and determines that the client is wheezing, has chills, and back pain. What is the priority action of the nurse?
stop the transfusion. Explanation: Symptoms of wheezing, chills. and back pain may indicate a blood transfusion reaction, which is a medical emergency. The nurse should immediately stop the transfusion and then notify the primary RN or charge nurse. The head of the bed should be raised to aid in respiration and oxygen should be administered in high doses. The primary RN or charge nurse will notify the physician and the laboratory or blood bank.
The nurse is caring for a child with leukemia. Which medication, that is administered as prophylaxis against pneumocystis pneumonia (PCP), does the nurse anticipate needing to reinforce education for the parents?
sulfamethoxazole-trimethoprim Explanation: The most common cause of death from leukemia is overwhelming infection. Pneumocystis pneumonia infection is lethal to a child with leukemia. As prophylaxis against pneumocystis pneumonia, continuous low dosages of sulfamethoxazole-trimethoprim are usually prescribed. Oral nystatin suspension would be indicated for the treatment of thrush. Prednisone isn't an antibiotic and increases susceptibility to infection. Vincristine is an antineoplastic agent.
Which symptom is the most common manifestation of severe combined immunodeficiency disease (SCID)?
susceptibility to infection Explanation: SCID is characterized by absence of both humoral and cell-mediated immunity. The most common manifestation is susceptibility to infection early in life, most commonly by age 3 months. Increased bruising and prolonged bleeding aren't manifestations of SCID. Failure to thrive is a consequence of persistent illnesses.
A client has moved into the acquired immunodeficiency syndrome (AIDS) phase of the human immunodeficiency virus (HIV) positive infection. The nurse advises the client to avoid what outdoor recreational activity?
swimming in rivers or lakes Explanation: When a client with HIV has moved into the AIDS phase of the infection, the client has a very low CD4 count (<200) and is at high risk for opportunistic infections. One such infection is cryptosporidia, which is caused by protozoan parasites that are often found in water. Swimming in a river or lake greatly increases the risk of this exposure. While the client should take protection to avoid pathogens or injury during the other activities listed, none are known to carry a specific risk for the client that the nurse would need to emphasize compared to the risk of cryptosporidia infection from swimming in lakes or rivers. Remediation:
