Review Qs
The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question? "Have you ever had a transfusion before?" "Why do you think that you need the transfusion?" "Have you ever gone into shock for any reason in the past?" "Do you know the complications and risks of a transfusion?"
"Have you ever had a transfusion before?"
A client with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate neutropenia, and protective isolation procedures are initiated. A visitor brings fresh flowers picked from her garden, and asks the nurse for a vase to put them in. Which response should the nurse provide to the visitor? "I have a vase in the utility room, I will get it for you". "I will get the vase and wash it well before you put the flowers in it". "The flowers from your garden are beautiful but should not be placed in the patient's room at this time". "When you bring flowers into the room place them on the bedside stand as far away from the patient as possible".
"The flowers from your garden are beautiful but should not be placed in the patient's room at this time".
The clinic nurse prepares a teaching plan for a client receiving antineoplastic medication. When implementing the plan, the nurse should make which statement to the client? "You can take aspirin as needed for a headache". "You can drink beverages containing alcohol in moderate amounts each evening". "You need to consult with the health care provider before receiving immunizations". "It is fine to receive a flu vaccine at the local health fair without healthcare provider approval because the flu is so contagious".
"You need to consult with the health care provider before receiving immunizations".
The nurse begins a routine blood transfusion of packed red blood cells (PRBCs) at 1100. To ensure client safety, the unit of blood should be completely transfused by what time? 1115 1500 1530 1600
1500
The nurse is performing an assessment on a client suspected to have hodgkin's disease. Which assessment findings are specifically characteristic of this disease? Select all that apply
Abdominal pain. Painless, firm, and movable adenopathy in the cervical area.
A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? Select all that apply
Administer oxygen. Quickly assess the client's respiratory status. Document the events, interventions, and the client's response.
When caring for a client with internal radiation implant, the nurse should observe which principles? Select all that apply
Keeping pregnant women out of the client's room. Placing the client in a private room with a private bath. Wearing a lead shield when providing direct patient care.
Which of the following factors may adversely affect the clotting process? Liver disease Renal failure H2-receptor blockers Antibiotic therapy
Liver disease
During an infusion of packed for blood cells, the client develops shortness of breath, cough, tachycardia, and crackles in both lung bases. Which action should the nurse implement first? Maintain bed rest with legs elevated. Place the client in high fowler's position. Increase the rate of IV fluid infusion. Consult with the health care provider regarding initiation of oxygen therapy.
Place the client in high fowler's position.
The nurse is performing an assessment on a patient with acute myeloid leukemia (AML) and observes multiple areas of ecchymosis and petechiae. What laboratory study should the nurse be concerned about? WBC count of 4,200 cells/mcL Hemoglobin 13 g/dL Platelet count of 9,000/mm3 Creatinine level of 1.0 mg/dL
Platelet count of 9,000/mm3
The nurse is conducting allergy skin testing on a client. Which post procedure interventions are most appropriate? Select all that apply
Record site, date, and time of the test. Give the client a list of potential allergens if identified.
A diagnosis of Hodgkin's disease is suspected in a client. Several diagnostic studies are performed to determine the presence of this disease. Which diagnostic test will confirm the diagnosis of Hodgkin's disease? Elevated vanillymandelic acid urinary levels The presence of blast cells in the bone marrow The presence of Epstein Barr virus in the blood The presence of Reed Sternberg cells in the lymph nodes
The presence of Reed Sternberg cells in the lymph nodes
The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item? Vital signs Skin color Urine output Latest hematocrit level
Vital signs
The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan? encouraging fluids providing frequent oral care coughing and deep breathing monitoring red blood cells
encouraging fluids
A nurse is assessing a client with multiple myeloma. The nurse should keep in mind that clients with multiple myeloma are at risk for: chronic liver failure. acute heart failure. pathologic bone fractures. hypoxemia.
pathologic bone fractures.
The health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? Hairdressers The homeless Children in daycare centers Individuals living in a group home
Hairdressers
The nurse analyzes laboratory values of a client with leukemia who was receiving chemotherapy. The nurse notes that the platelet count is 19,500. On the basis of this lab result, what intervention should the nurse include in the plan of care Initiate bleeding precautions. Monitor closely for signs of infection. Monitor the temperature every four hours. Initiate protective isolation.
Initiate bleeding precautions.
Which nursing interventions are implemented in the care of a client with leukemia who is at risk for infection? Select all that apply
Reduce exposure to environmental organisms. Use strict aseptic technique for all procedures. Ensure that anyone entering the client's room wears a mask.
The nurse is assessing a patent with polycythemia vera. What skin assessment data would the nurse determine is a normal finding for this patient? Pale skin and mucous membranes Bronze skin tone Ruddy complexion Jaundice skin and sclera
Ruddy complexion
The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client? Wearing gloves Wearing a gown and gloves Wearing a gown, gloves, and a mask Wearing a gown and gloves to change the bed linens, and gloves only for the bath
Wearing a gown and gloves
A nurse is reviewing a client's morning laboratory results and notes a left shift in the band cells. Based on this result, the nurse can interpret that the client may be developing an infection. may be developing anemia. has leukopenia. has thrombocytopenia.
may be developing an infection.
The nurse is caring for a client following mastectomy. Which intervention would assist in preventing lymphedema of the affected arm? Placing cool compresses on the affected arm Elevating the affected arm on a pillow above heart level Avoiding arm exercises in the immediate postoperative period Maintaining an IV site below the antecubital area on the affected side
Elevating the affected arm on a pillow above heart level
The nurse is Monitoring the IV infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. On inspection of the site, the nurse notes redness and swelling and that the infusion of the medication has slowed. The nurse suspects extravasation and should take which actions? Select all that apply
Stop the infusion. Notify the health care provider. Prepare to apply ice or heat to the site. Prepare to administer a prescribed antidote into the site.