Week 1: Immune & Hematologic Disorders

A client with mild dementia related to end-stage acquired immunodeficiency syndrome is preparing for discharge. The client has decided against further curative treatment and wishes to return home. Before discharge, the client develops ocular cytomegalovirus (CMV). The physician recommends treatment with a ganciclovir-impregnated implant, which requires a surgical procedure. The client's partner feels the implant won't help the client and asks the nurse if the implant will cure CMV. Which answer from the nurse best answers the partner's question reflecting client advocacy?

"The implant won't cure the virus, but it may help preserve your partner's vision. Not being able to see you or the surroundings may worsen your partner's dementia and make caring for your partner at home more difficult." The nurse is advocating for the client's wishes when explaining the client's wishes for no further curative treatment, yet promoting an improved quality of life and safety while the client is being cared for at home. There is no cure for CMV unless the surgical procedure is done. "Nothing more will help your partner" provides factual information, but it's delivered in a confrontational manner

The nurse is planning care for a client who has an allergy to latex. What intervention would be the priority for the nurse to include in the plan of care?

Place latex-free, powder-free gloves at client's bedside. Latex-free, powder-free gloves reduce the risk of respiratory exposure to latex. Having them conveniently located will enhance staff adherence, so this is the most important intervention. Using oil-based hand lotion should be avoided when wearing latex gloves because this increases risk of latex breakdown and can increase latex exposure for the person wearing the gloves. However, the client can have oil-based lotions applied to the skin as this is not contraindicated. Obviously, the nurse would wear latex-free gloves for application, or no gloves at all if no contact with body fluids is expected. Having a roommate with a latex catheter does not pose a risk of direct exposure for the client. Clients with latex allergies should have clear signage but do not require a private room.

The client with hepatitis A is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. What is the most appropriate goal for this client?

Gradually increase activity tolerance. The most appropriate goal for this client with hepatitis is to increase activity gradually as tolerated. Periods of alternating rest and activity should be included in the plan of care. There is no evidence that the client is physically immobile, unable to provide self-care, or needs to adapt to new energy levels.

A nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?

Use the smallest needle possible for injections. Because thrombocytopenia alters coagulation, it poses a high risk of bleeding. To help prevent capillary bleeding, the nurse should use the smallest needle possible when administering injections. The nurse doesn't need to limit visits by family members because they don't pose any danger to the client. The nurse should provide comfort measures and maintain the client on bed rest; activities such as using a wheelchair can cause bleeding. The nurse records fluid intake and output to monitor hydration; however, this action doesn't protect the client from a complication of thrombocytopenia.

A client being treated for iron deficiency anemia with ferrous sulfate continues to be anemic despite treatment. The nurse should assess the client for use of which medication?

aluminum hydroxide The nurse should assess the client for possible use of antacids such as aluminum hydroxide. Clients should take ferrous sulfate and an antacid at least 2 hours apart because antacids bind with iron in the GI tract, decreasing the rate or extent of iron absorption.

A nurse is monitoring a client who developed facial edema after receiving a medication. What should the nurse do next?

Assess for shortness of breath. The client's edema is related to an allergic reaction to the medication. Further assessment of the airway is necessary given the location of edema. After notifying the physician, the medication should be changed and treatment given, based on the assessment findings.

A client receiving a blood transfusion begins to have chills and headache within the first 15 minutes of the transfusion. What should the nurse do first?

Discontinue the transfusion. Chills and headache are signs of a febrile, nonhemolytic blood transfusion reaction, and the nurse's first action should be to discontinue the transfusion as soon as possible and then notify the health care provider (HCP). Antipyretics and antihistamines may be prescribed. The nurse would not administer acetaminophen without a prescription from the HCP. The client's blood pressure should be taken after the transfusion is stopped. Checking the infusion rate of the blood is not a pertinent action; the infusion needs to be stopped regardless of the rate.

The nurse is assisting with a bone marrow aspiration and biopsy. Place the tasks in the order in which the nurse should perform them, from highest priority to least priority. All options must be used.

Verify the client has signed an informed consent. Position the client in a side-lying position. Clean the skin with an antiseptic solution. Apply ice to the biopsy site. First, the nurse must verify that the client has voluntarily signed a consent form before the procedure begins and check that the client understands the procedure. The nurse then positions the client in a side-lying, or lateral decubitus, position with the affected side up. Then, the nurse should clean the skin site and surrounding area with an antiseptic solution before the health care provider (HCP) numbs the site and collects the specimen. When the procedure is finished, the nurse must apply ice to the biopsy site to reduce pain.

A client from a Mediterranean country is admitted with thalassemia, jaundice, splenomegaly, and hepatomegaly. Which should be the primary focus of nursing care for this client?

Decrease cardiac demands by promoting rest. This client has clinical manifestations of thalassemia major, a disease found in descendants from the Mediterranean Sea area whose mother and father both possess a gene for thalassemia (i.e., the client is homozygous for the gene). The severe hemolytic anemia causes sequestration of red blood cells in the spleen and liver, which leads to engorgement of the organs and chronic bone marrow hyperplasia. Rest will decrease the demands on the heart due to the diminished hemoglobin level, a physiologic concern. The nurse should follow the time schedule of the area in which the client is now living. The nurse can help the client prescribe preferred foods and listen to concerns, but the main priority is to decrease oxygen demands.

A client has been admitted with a left tibial fracture and extensive soft-tissue injuries, and there is a concern for the development of disseminated intravascular clotting (DIC). Which interventions by the nurse are priorities for this client? Select all that apply.

Improve tissue oxygenation, replace fluids, and correct electrolyte imbalances. Assess for any signs of bleeding in the gums and other mucous membranes. It is most important that tissue oxygenation be preserved, as circulation is impaired. In addition, fluid replacement and correction of electrolyte imbalance is critical. It is also a priority to assess for any signs of bleeding, as this can be an early indicator of DIC. The mortality rate can be 80% in clients who develop disseminated intravascular clotting. The priorities are not replacement of blood or administering antihypertensive medications.

The nurse is developing a plan of care for a client who has joint stiffness due to rheumatoid arthritis. Which measure will be the most effective in relieving stiffness?

a warm shower before performing activities of daily living Warm showers, baths, or hand soaks can help relieve joint stiffness and allow the client to more comfortably perform activities of daily living. Aspirin or other anti-inflammatory drugs should be taken before activity to help decrease inflammation and reduce joint pain and inflammation. Although weight loss may decrease stress on joints, pain and stiffness will continue to be a problem. Cold compresses are most effective for relieving joint pain, whereas moist heat is useful for decreasing pain and stiffness. When cold compresses are applied, their use should be limited to 10 to 15 minutes at a time to decrease the risk of tissue damage.

A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information?

Autoimmune disorders include connective tissue (collagen) disorders. Connective tissue disorders are considered autoimmune disorders. Clients with autoimmune disorders may have either false-positive or false-negative serologic tests for syphilis. Other common laboratory findings in these clients include Coombs-positive hemolytic anemia, thrombocytopenia, leukopenia, immunoglobulin excesses or deficiencies, antinuclear antibodies, antibodies to deoxyribonucleic acid and ribonucleic acid, rheumatoid factors, elevated muscle enzymes, and changes in acute phase-reactive proteins. No cure exists for autoimmune disorders; treatment centers on controlling symptoms. Autoimmune disorders aren't distinctive; they share common features, making differential diagnosis difficult.

A young adult has been bitten by a human, and the skin on the forearm is broken. The client's last tetanus shot was about 8 years ago. What should the nurse tell the client about the anticipated treatment plan?

"You'll need an injection of tetanus toxoid." Tetanus toxoid is indicated because there has been no booster in the last 5 years. With a human bite, there is a risk of severe infection; application of a steroid cream does not prevent infection. The closure of the wound should be delayed until it is determined that there is no infection, in approximately 24 to 48 hours. Rabies is not transmitted through human bites.

After one week in the hospital for chemotherapy treatment related to lymphocytic leukemia, a client develops abdominal pain, fever, and foul-smelling diarrhea. What priority recommendation does the nurse make to the healthcare provider?

Collect stool sample for Clostridium difficile. Immunosuppressed clients — for example, clients receiving chemotherapy — are at risk for infection with C. difficile, which causes foul-smelling diarrhea. Successful treatment begins with an accurate diagnosis, which includes a stool test. A stool culture and sensitivity does not test specifically for C. diff and is not recommended for clients who have been hospitalized for more than 3 days. The nurse should collect the sample and institute contact precautions prior to conducting further assessments related to fluid balance. The nurse would not request an antidiarrheal until the cause of the diarrhea is known.

A 35-year-old female client is diagnosed with aplastic anemia. Which is the most important nursing measure to incorporate into the client's plan of care?

Alternate periods of activity with rest to decrease fatigue. Activity intolerance is a common problem for clients with aplastic anemia due to decreased hemoglobin. Alternating activity with periods of rest and assisting the client with activities of daily living are appropriate nursing interventions.Antibiotics will not be administered prophylactically. The client should be taught self-care activities to decrease the likelihood of developing an infection.Adequate fluid intake is important, but the client does not need to force fluids. Hemoconcentration is not a problem in aplastic anemia.The client should be taught good handwashing techniques and limit contact with individuals who have respiratory illnesses; however, the client does not have to avoid all social situations.

The nurse is developing a teaching plan for the client with aplastic anemia. Which is most important to include in the plan?

Avoid exposure to others with acute infections. Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia. Strict aseptic technique and reverse isolation are important measures to prevent infection. Although diet, reduced stress, and rest are valued in supporting health, the potentially fatal consequence of an acute infection places it as a priority for teaching the client about health maintenance. Animal meat and dark green leafy vegetables, good sources of vitamin B12 and folic acid, should be included in the daily diet. Yoga and meditation are good complementary therapies to reduce stress. Eight hours of rest and naps are good for spacing and pacing activity and rest.

A client undergoing antineoplastic therapy is prescribed subcutaneous epoetin. What indicates to the nurse that the drug has been effective?

Hemoglobin levels rise. Epoetin stimulates erythropoiesis and the production of RBCs. This is important for clients taking antineoplastics because they often suffer bone marrow depression as a side effect of antineoplastic therapy. Epoetin does not affect tissue malignancy or tumor size. Nausea and vomiting are commonly associated with antineoplastics, but these are treated with antiemetics.

Which iron-rich foods should a nurse encourage an anemic client requiring iron therapy to eat?

lamb and peaches Iron-rich foods include lamb and peaches. Shrimp, tomatoes, lobster, squash, cheese, and bananas aren't high in iron content.

A client with rheumatoid arthritis is being discharged with a prescription for aspirin, 600 mg P.O. every 6 hours. Which statement by the client indicates understanding of the adverse effects of the medication?

"I'll call my physician if I have ringing in the ears." The client with rheumatoid arthritis typically takes a relatively high dosage of aspirin for its anti-inflammatory effect. The nurse should instruct the client to report signs and symptoms of aspirin toxicity, such as tinnitus (ringing in the ears). Dysuria and constipation are not associated with aspirin use or toxicity. Bleeding is, so the client is instructed to take with food.

A nurse is preparing to administer a unit of blood to a client with anemia. After its removal from the refrigerator, the blood should be administered within:

4 hours. Refrigeration delays the growth of bacteria in the blood. After the blood is removed from the refrigerator, it must be administered within 4 hours. If the blood is administered too rapidly, within 1 or 2 hours, the client could experience fluid overload. Six hours is too long because the extended time out of refrigeration increases the risk of contamination and growth of bacteria.

A client with rheumatoid arthritis states, "I cannot do my household chores without becoming tired. My knees hurt whenever I walk." Which goal for this client should take priority?

Conserve energy. Based on the information from the client, the nurse should develop a plan with the client that will conserve energy and decrease episodes of fatigue. Although the client may develop a self-care deficit related to the increasing joint pain, the client is voicing concerns about household chores and difficulty around the house and yard, not self-care issues. Over time, the client may have difficulty coping, but that is not the current concern. Employing cleaning services may not be within the client's budget, and the client should first try a plan that balances rest and activity.

A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated?

IgE Immunoglobulin E (IgE) is involved with an allergic reaction. IgA combines with antigens and activates the complement system. IgB coats the surface of B lymphocytes. IgG is the principal immunoglobulin formed in response to most infectious agents.

A client being treated for leukemia has an absolute neutrophil count of 400 cells/mm3. What precautions would the nurse include in the plan of care?

Place sign on client's door reminding all persons to wash hands prior to entering. Neutropenia occurs when the absolute neutrophil count falls below 1,000 cells/mm3; a value of less than 500 cells/mm3 reflects a severe risk of infection. The nurse should protect the client by promoting strict hand hygiene for all persons who enter the client's room. The client may be placed in a private room with positive pressure, not negative, as the latter brings exterior air into the client's room. Clients with neutropenia should avoid rectal trauma, which may occur with suppositories or enemas. The nurse will not request routine antipyretic therapy, because this could mask a fever. Development of a fever while neutropenic, known as febrile neutropenia, is an oncological emergency.

The nurse is developing a care plan for a client who has had radiation therapy for Hodgkin's lymphoma. What is the primary goal of care for this client?

Prevent infection. The client with Hodgkin's lymphoma who has had radiation therapy is prone to infection; therefore, the primary goal is to prevent infection. The nurse instructs the client to perform frequent hand hygiene, avoid crowded areas, and report a temperature over 100°F (37.7°C). Maintaining fluid balance, exercising, and maintaining mental health are also important, but these are not primary goals at this time.

The nurse explains to the client that a biopsy of the enlarged lymph node is important because, if Hodgkin's disease is present, the histologic examination will reveal which of the following?

Reed-Sternberg cells. A definitive diagnosis of Hodgkin's disease is made if Reed-Sternberg cells are found in the histologic examination of the excisional lymph node biopsy. Tay-Sachs disease is an inherited disease carried by an autosomal recessive gene. Sarcoidosis is an inflammatory granulomatous disease. Duchenne's disease is a type of muscular disorder.

A client with thrombocytopenia has just had a bone marrow aspirate performed to monitor for treatment effectiveness. Which nursing intervention takes priority?

applying pressure to the puncture site for a full 10 minutes A pressure dressing may be needed, but immediate pressure for a full 10 minutes is necessary to stop bleeding in the case of thrombocytopenia. A bandage is usually applied to the site. Vital signs will be monitored but do not need to be monitored more frequently, nor is infection an immediate priority

A client with autoimmune thrombocytopenia and a platelet count of 8,000/μl develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery — this will go away on its own." In considering her response to the client, the nurse must depend on the ethical principle of:

autonomy. Autonomy is the right of the individual to make his own decisions. In this case, the client is capable of making his own decision and the nurse should support his autonomy. Beneficence, promoting and doing good, and justice (being fair) aren't the principles that directly relate to the situation. Advocacy is the nurse's role in supporting the principle of autonomy.

The client who does not respond adequately to fluid replacement has a prescription for an IV infusion of dopamine hydrochloride at 5 mcg/kg/min. To determine that the drug is having the desired effect, what should the nurse assess?

increased cardiac output At medium doses (4 to 8 mcg/kg/minute), dopamine hydrochloride slightly increases the heart rate and improves contractility to increase cardiac output and improve tissue perfusion. When given at low doses (0.5 to 3.0 mcg/kg/minute), dopamine increases renal and mesenteric blood flow. At high doses (8 to 10 mcg/kg/minute), dopamine produces vasoconstriction, which is an undesirable effect. Dopamine is not given to affect preload and afterload.

The nurse is collaborating with the dietician to plan the diet of a client with a latex allergy. Which foods should not be included in the client's meal plan? Select all that apply.

tomato soup grapes potatoes Foods with known cross-reactivity to latex include tomatoes, grapes, and potatoes, as well as many others. Therefore, these foods should be avoided by someone with a latex allergy. Macaroni and cheese and green beans are safe for the client to consume.

A 23-year-old female client diagnosed with HIV is receiving lamivudine. Which assessment finding would require the nurse to notify the healthcare provider?

Currently breast feeding 1-month-old baby Because of the potential for HIV transmission, women taking lamivudine should not breast feed as is transferable to the breast-fed infant. Pregnant clients can take lamivudine and it is one of the preferred drugs. A client positive for HIV would have a low CD4 count and a positive HIV assay, and the WBC count of 6,000 mm3 is within normal limits.

A nurse is teaching a client who has a severe allergy to bee stings how to manage a reaction. What medication does the nurse encourage the client to take first after being stung by a bee?

epinephrine A client who develops anaphylaxis may take all the listed medications, but epinephrine, a non-selective adrenergic agonist, should be administered intramuscularly first. The client may then use the albuterol to help open airways. Diphenhydramine, an H1 antihistamine, may also be taken, but this is only effective to reduce itching and will not help with airway symptoms. Finally, prednisone is not generally prescribed PRN and would be taken only under advice of the healthcare provider once the client reaches medical attention.

A client with rheumatoid arthritis has been on aspirin therapy for an extended time. Which assessment is the most important for the nurse to obtain?

hearing Prolonged use of aspirin and other salicylates sometimes causes bilateral hearing loss of 30 to 40 decibels. Usually, this adverse effect resolves within 2 weeks after the therapy is discontinued. Aspirin doesn't lead to weight gain, gait problems, or changes in muscle mass.

A nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (HCT) in this client?

hemodilution Reduced HCT is caused by hemodilution, in which volume overload resulting from interstitial-to-plasma fluid shift lowers the concentration of erythrocytes and other blood elements. Hemoconcentration results from hypoalbunimemia, which causes the movement of fluid from the vascular component to the interstitial space. Metabolic acidosis does cause the red blood cell components to be fragile, but it isn't related to reduced HCT level in this situation. Erythropoietin factor is reduce if kidney failure occurs; however, lack of erythropoietin factor doesn't impact hematocrit level.

The nurse reviews the laboratory results for a client with type 2 diabetes who is scheduled for surgery in about one month. What result should the nurse notify the healthcare provider about as most relevant to the preoperative plan of care?

low hematocrit (HCT) and hemoglobin (Hb) levels Low preoperative HCT and Hb levels indicate the client may require a plan for banking of blood (autologous transfusion) or other blood-conservation techniques prior to surgery. Given the procedure is a month away, this means the healthcare team can make plans to offset the risk of anemia related to surgical blood loss. Low urea and creatinine levels are not significant findings, and the neutrophil count of 75% falls within normal parameters. A single elevated random blood glucose result does little to direct care. Rather than focus on this single result, the nurse would examine the glycated hemoglobin level and the client's overall glucose trends to direct preoperative glucose management.

The teaching plan for the client with rheumatoid arthritis includes rest promotion. What position of the involved joints should the nurse tell the client to avoid when at rest?

maintaining the joints in a flexed position Positions of flexion should be avoided to prevent loss of functional ability of affected joints. Proper body alignment during rest periods is encouraged to maintain correct muscle and joint placement. Lying in the prone position is encouraged to avoid further curvature of the spine and internal rotation of the shoulders.

Which is an appropriate outcome for a client with rheumatoid arthritis who is receiving anti-inflammatory drugs and physical therapy? The client will:

manage joint pain and fatigue to perform activities of daily living. An appropriate outcome for the client with rheumatoid arthritis is that he will adopt self-care behaviors to manage joint pain, stiffness, and fatigue and be able to perform activities of daily living. Range-of-motion (ROM) exercises can help maintain mobility, but it may not be realistic to expect the client to maintain full ROM. Depending on the disease progression, there may be further development of pain and joint deformity, even with appropriate therapy. It is important for the client to understand the importance of taking the prescribed drug therapy even if symptoms have abated.

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?

platelet count, prothrombin time, and partial thromboplastin time The diagnosis of DIC is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, fibrinogen level, and D-dimer, as well as client history and other assessment factors. Red blood cell count and hemoglobin are not utilized in this diagnosis.

The nurse is completing a health history review of a client who has received long term medical steroid therapy for lupus. Which client data does the nurse recognize as potentially linked to the steroid use?

three infections over the course of the year acne noted on the forehead, cheeks, and back Suppression of the immune system occurs when a client receives long term steroid therapy, making the client more susceptible to infections. Acne is present related to oily skin and also the overproduction of the acne bacterium, Propionibacterium acnes. Also, changes in metabolism occur leading to weight gain, not weight loss. Nausea and hypertension are not commonly seen with steroid use.

The nurse is working in an internal medicine office. A child brings a parent to the health care provider's appointment. Upon reviewing the medication list, the daughter states, "Which medication is prescribed to prevent a stroke?" The nurse is correct to answer which medication?

ticlopidine Ticlopidine inhibits platelet aggregation by interfering with adenosine diphosphate release in the coagulation cascade and, therefore, is used to prevent thromboembolic stroke. Allopurinol is an antigout medication used to reduce uric acid. Loratadine is an over-the-counter allergy medication. Methylprednisolone, a steroid with anticoagulant properties, is not used to treat thromboembolic stroke.

A client has back pain 10 minutes after a unit of packed red blood cells (RBCs) was started. The client's pulse, blood pressure, and respirations are stable, and similar to vital signs obtained before infusing the RBCs. What should the nurse do? Select all that apply.

Turn off the infusion of the packed RBCs. Send the remaining blood to lab. Prepare for cardiopulmonary resuscitation. Obtain a urine specimen to send to the laboratory. When a client begins to have back pain with administration of blood, the nurse should suspect a hemolytic reaction, and the blood transfusion should be stopped immediately. Any remaining blood and the tubing should be sent to the lab. The nurse should prepare for a reaction from mild to severe, including the need for cardiopulmonary resuscitation, because even a small amount of mismatched blood can lead to a major reaction. The nurse should obtain a urine specimen to send to the laboratory to check for hemoglobin because RBC hemolysis filters through the kidneys from the reaction. The nurse should stop the IV line with the Y-tubing for the blood and not flush the line with saline so that the client does not receive any more blood. The tubing should be changed so that a tube without blood can be used for infusions.

A client has been taking a decongestant for allergic rhinitis. Which finding suggests that the decongestant demonstrates maximum therapeutic effective?

reduced sneezing Decongestants relieve congestion and sneezing and reduce labored respiration rate. It is anticipated that decongestants dry the mucous membranes, these are commonly reported side effects. The anticipated therapeutic effect would be demonstrated with a decrease in sneezing.

The nurse is providing care to a pediatric client having an anaphylactic reaction. Place the below nursing assessments in order based on priority. All options must be used.

Assess respiratory rate. Listen to breath sounds. Palpate and compare pulses. Assess level of consciousness. Obtain a brief history. Ask if the child has received any medication since the onset of symptoms. Assessment of respiratory rate establishes if the client is breathing and if the airway is adequate. Assessment of breath sounds determines the patency of the airway. Palpating pulses determines if circulation is sufficient. Those are all priority assessments. Then LOC can be assessed. History and medications can be assessed after the client is stabilized.

A client admitted with bacterial pneumonia develops a fever. Which health care provider order should the nurse implement first?

Draw blood cultures from two sites. Blood cultures should be obtained before antibiotic administration in order to avoid altering the culture results—this is the priority. Both acetaminophen administration and portable chest x-ray can wait until the blood cultures are obtained and the antibiotics are started.

A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client needs further nutritional counseling?

The client drinks coffee or tea with meals. Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron. Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a nonheme or nonanimal iron source. Cooking in iron cookware, especially acid-based foods such as tomatoes, adds iron to the diet. Clients are instructed to add a rich supply of vitamin C to every meal because the absorption of iron is increased when food with vitamin C or ascorbic acid is consumed.

The nurse plans to administer an injection of heparin to a client. Which technique for heparin administration is appropriate? The nurse:

applies gentle pressure to the site for 5 to 10 seconds after the injection. Gentle pressure should be applied after the injection, but the area must not be massaged. Heparin is administered subcutaneously, never intramuscularly. A 25- or 26-gauge, ½- to 5/8-inch (1.3- to 1.6-cm) needle is most appropriate for heparin administration. The fatty layer of the abdomen is the preferred injection site. The nurse should select a site 1 to 2 inches (2.5 to 5 cm) away from the umbilicus, scar tissue, or any bruises. To decrease the risk of hematoma formation and tissue damage, aspiration of the plunger should be avoided.

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 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 client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product?

normal saline solution as this is considered an isotonic solution Normal saline solution is used for administering blood transfusions. Lactated Ringer's solution or dextrose solutions may cause blood clotting or RBC hemolysis. Current guidelines do not indicate a "no priming" method without NSS.

A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching?

"I can eat whatever I want as long as it's low in fat." The client requires additional teaching if they state that they can eat whatever they want. Immunosuppressed clients should avoid raw fruit and vegetables because they may contain bacteria that could increase the risk of infection; foods must be thoroughly cooked. Avoiding people who are sick, products containing alcohol, and people who have just received vaccines are appropriate actions for an immunosuppressed client.

The client with rheumatoid arthritis tells the nurse, "I have a friend who took gold shots and had a wonderful response. Why didn't my health care provider let me try that?" Which response by the nurse would be most appropriate?

"Every person is different. What works for one client may not always be effective for another." The nurse's most appropriate response is one that is therapeutic. The basic principle of therapeutic communication and a therapeutic relationship is honesty. Therefore, the nurse needs to explain truthfully that each client is different and that there are various forms of arthritis and arthritis treatment. To state that it is the HCP's prerogative to decide how to treat the client implies that the client is not a member of his or her own health care team and is not a participant in his or her care. The statement also is defensive, which serves to block any further communication or questions. Asking the client to tell more about the friend presumes that the client knows correct and complete information, which is not a valid assumption to make. The nurse does not know about the client's friend and should not make statements about another client's condition. Stating that the drug is for advanced disease demonstrates that the nurse is making assumptions that are not necessarily valid or appropriate. Also, telling the client that he or she is not eligible for the drug now is not within the scope of the nurse's practice.

A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis?

"My finger joints are oddly shaped." Joint abnormalities are the most obvious manifestations of rheumatoid arthritis. A systemic disease, rheumatoid arthritis attacks all connective tissue. 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 in the hands, although common in rheumatoid arthritis, are painless. The disease may cause gait disturbances, but these follow joint abnormalities.

A client with acquired immunodeficiency syndrome (AIDS) is ordered zidovudine, 200 mg P.O. every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?

"Take zidovudine every 4 hours around the clock." To be effective, zidovudine must be taken every 4 hours around the clock. Food doesn't affect absorption of this drug, so the client may take zidovudine either with food or on an empty stomach. To avoid serious drug interactions, the client should check with the physician before taking OTC medications.

A nurse is teaching a young adult female client about self-management of systemic lupus erythematosus (SLE). The client is prescribed ibuprofen, hydroxychloroquine, and cyclophosphamide. The client asks the nurse about the possibility of becoming pregnant while being treated for SLE. What is the nurse's best response?

"You should speak with your healthcare provider about alternatives to taking cyclophosphamide." The most important piece of information in this moment is the advice to prevent pregnancy while on cyclophosphamide and to encourage the client to explore safer options if she wishes to become pregnant in the future. This drug is pregnancy category D, and there is a high risk of long-term fertility issues for women who take this medication. Tell the client that there may be a more appropriate alternative. Antimalaria medications such as hydroxychloroquine are usually continued during pregancy, and ibuprofen poses a small risk during pregnancy. While there is a higher risk for miscarriage and fertility issues, this is not priority information for the client in this moment. While there is some genetic component to how SLE develops, there is no clear or strong pattern of heredity.

A client with human immunodeficiency virus (HIV) infection is taking zidovudine (AZT). What is the expected outcome of AZT for this client?

Enable slow replication of the virus. Zidovudine (AZT) interferes with replication of HIV and thereby slows progression of HIV infection to acquired immunodeficiency syndrome (AIDS). There is no known cure for HIV infection. Today, clients are not treated with monotherapy but are usually on triple therapy due to a much-improved clinical response. Decreased viral loads with the drug combinations have improved the longevity and quality of life in clients with HIV/AIDS. AZT does not destroy the virus, enhance the body's antibody production, or neutralize toxins produced by the virus.

The nurse is caring for a client admitted with severe blood pressure 80/40 hypotension and positive blood cultures for Escherichia coli. What are the priority interventions for this client? Select all that apply.

Maintain intravenous fluids and vasopressors. Administer ceftriaxone. This client requires antibiotics, fluids, and vasopressors. With severe hypotension, this is not the ideal teaching time for the client. Visitors do not need to be restricted. A negative-pressure room is not indicated for this client.

The nurse is teaching a female client about taking folic acid supplements for folic acid deficiency anemia. What information should be included in the teaching plan?

Oral contraceptive use, pregnancy, and lactation increase daily requirements. Oral contraceptive use, pregnancy, and lactation are situations that increase demand for folic acid. With supplementation, a response should cause the reticulocyte count to increase within 2 to 3 days after therapy has begun. It is not necessary to take folic acid on an empty stomach. A client may safely take both iron and folic acid supplementation.

A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?

Pallor, tachycardia, and a sore tongue Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina pectoris; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision aren't characteristic findings in pernicious anemia.

When developing the plan of care for a client with aplastic anemia, the nurse should include which goal?

Perform activities of daily living without excessive fatigue or dyspnea. With aplastic anemia, measures to conserve energy and reduce oxygen requirements are essential. Therefore, an appropriate goal would be to strive to perform activities of daily living without excessive fatigue or dyspnea. The client needs adequate vitamin B12 in the diet. However, vitamin B12 injections usually are not required. Anticoagulants are contraindicated in clients with low platelet counts, which often occur in aplastic anemia. Aplastic anemia is not contagious. Thus, measures to prevent transmission are inappropriate.

The nurse is teaching a client with a latex allergy about birth control methods to protect against sexually transmitted diseases. What information should be included in the teaching? Select all that apply.

Use of latex condoms, cervical caps, and/or diaphragms are contraindicated for men and women with latex allergy. A natural condom can be placed over a latex condom for protection. The use of latex condoms, cervical caps, and/or diaphragms are contraindicated for men and women with latex allergy due to the risk for anaphylaxis. It is appropriate to place a natural condom over a latex condom for protection. Female condoms are made of polyurethane and can be used. Oral contraceptives are not a good substitute, as they will not protect from STIs.

Which step must be done first when administering a blood transfusion?

Verify the physician's order. The nurse must first verify the physician's order and then make sure the informed consent form is signed. Next, the nurse should make sure that an appropriate-size I.V. catheter is in place and the nurse should assess the site for patency. After doing so, the nurse should verify the blood product and client identity with another nurse.

The nurse is caring for a client in sickle cell crisis. What nursing action is the highest priority?

administering analgesics as prescribed In sickle cell crisis, sickle-shaped red blood cells clump together in a blood vessel, which causes occlusion, ischemia, and extreme pain. Therefore, pain management is a priority. Although nutrition is important, poor nutritional intake isn't necessarily related to sickle cell crisis. During sickle cell crisis, pain may disturb sleep, so controlling pain will assist with rest and sleep as well. Monitoring lab reports will be done, but that is not as urgent as pain control.

The nurse should assess a client at risk for acute disseminated intravascular coagulation (DIC) for which early sign?

bleeding without history or cause There is no well-defined sequence for acute DIC other than that the client starts bleeding without a history or cause and does not stop bleeding. Later signs may include severe shortness of breath, hypotension, pallor, petechiae, hematoma, orthopnea, hematuria, vision changes, and joint pain.

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption?

intrinsic factor Vitamin B12 absorption depends on intrinsic factor, which is secreted by parietal cells in the stomach. The vitamin binds with intrinsic factor and is absorbed in the ileum. Hydrochloric acid, histamine, and liver enzymes don't influence vitamin B12 absorption.

Which lab values should the nurse report to the health care provider (HCP) when the client has anemia?

intrinsic factor, absent The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B cannot be absorbed in the small intestine and folic acid needs vitamin B for deoxyribonucleic acid synthesis of RBCs. The gastric analysis is done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B, which is protocol for the first and second stage of the Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B in the intestinal tract. A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation; it is not specific to anemias. An RBC value within the normal range does not indicate an anemia.

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." 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 physician orders gentamicin sulfate, 80 mg I.V. every 8 hours for a client with Pseudomonas aeruginosa. The nurse should infuse this drug over at least:

30 minutes The nurse should infuse gentamicin sulfate I.V. over at least 30 minutes. Infusing the drug more rapidly may increase the client's risk of adverse reactions.

A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. The new graduate knows that the greatest likelihood of an acute hemolytic reaction would occur when giving

A-positive blood to an A-negative client. An acute hemolytic reaction occurs when there is an ABO or Rh incompatibility. For example, giving A blood to a B client would cause a hemolytic reaction. Likewise, giving Rh-positive blood to an Rh-negative client would cause a hemolytic reaction. It's safe to give Rh-negative blood to an Rh-positive client if there is a blood type compatibility. O-negative blood is the universal donor and can be given to all other blood types. AB clients can receive either A or B blood as long as there isn't an Rh incompatibility.

A client with macrocytic anemia has a burn on her foot and reports watching television while lying on a heating pad. Which action should be the nurse's first response?

Check for diminished sensations. Macrocytic anemias can result from deficiencies in vitamin B12 or ascorbic acid. Only vitamin B12deficiency causes diminished sensations of peripheral nerve endings. The nurse should assess for peripheral neuropathy and instruct the client in self-care activities for diminished sensation to heat and pain (e.g., using a heating pad at a lower heat setting, making frequent checks to protect against skin trauma). The burn could be related to abuse, but this conclusion would require more supporting data. The findings should be documented, but the nurse would want to address the client's sensations first. The decision of how to treat the burn should be determined by the health care provider (HCP).

A client with a suspected diagnosis of Hodgkin's disease is to have a lymph node biopsy. What should the nurse make sure that personnel involved with the procedure do?

Maintain sterile technique. The nurse must ensure that sterile technique is used when a biopsy is obtained because the client is at high risk for infection. In most cases, a lymph node biopsy is sent immediately to the laboratory once it is placed in a specific solution in a closed container. It is not necessary to wear a gown and mask when obtaining the specimen. It is not necessary to use special handling procedures for the instruments used.

On the fourth day after surgery, a client's incision is red and inflamed. There is moderate drainage from the incision. The client has a temperature of 102°F (38.9°C). The total white blood cell (WBC) count is 10,000/mm3 (10 × 109/L). What should the nurse do first?

Notify the health care provider (HCP). The findings (WBC count above normal, inflammation and drainage at the incision site, and an elevated temperature) indicate that the client has an infection. The nurse should first notify the HCP. Encouraging fluids will be helpful, but it is not the first action. The nurse should not cleanse the site or place a dressing over the incision until the HCP writes a prescription to do so.

A client is having a blood transfusion reaction. What must the nurse do in order of priority from first to last? All options must be used.

Stop the transfusion. Keep the IV open with normal saline infusion. Notify the health care provider (HCP) and blood bank. Complete the appropriate transfusion reaction form(s). When the client is having a blood transfusion reaction, the nurse should first stop the transfusion and then keep the IV open with normal saline infusion. Next, the nurse should notify the health care provider (HCP) and blood bank and then complete the required form(s) regarding the transfusion reaction.

A client is diagnosed with human immunodeficiency virus (HIV). What information does the nurse provide to best protect the client from advancing to the acquired autoimmodeficiency syndrome (AIDS) phase of this infection?

Strictly adhere to antiviral medication therapy. Antiretroviral therapy (ART) can control HIV and prevent the progression to AIDS. Missing doses of this therapy greatly increases the risk for increased viral activity. Making healthy lifestyle choices is good general advice but does not control viral activity as ART will. The client is not at high risk for contracting opportunistic infections simply by being HIV positive; the degree of risk depends on current cell counts. Once in the AIDS stage of infection, the client is at high risk for infection and needs to take protective measures. Safe sexual practices protect others from the virus.

At which time should the nurse instruct the client to take ibuprofen, prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation?

immediately after a meal Drugs that cause gastric irritation, such as ibuprofen, are best taken after or with a meal, when stomach contents help minimize the local irritation. Taking the medication on an empty stomach at any time during the day will lead to gastric irritation. Taking the drug at bedtime with food may cause the client to gain weight, possibly aggravating the osteoarthritis. When the client arises, he is stiff from immobility and should use warmth and stretching until he gets food in his stomach.

The nurse interviews a client with systemic lupus erythematosus (SLE) who reports to the emergency department with severe back pain after a minor fall. What aspect of the client's medical history is most relevant to the potential cause of this injury?

prescription for prednisone The client's back pain needs to be assessed as a potential fracture. The fact that the client is on a corticosteroid is the most relevant piece of information listed because it is associated with osteoporosis and can contribute to compression fractures of the spine. Anti-Sm antibodies can be used to help diagnose SLE, but this aspect of the history is not related to the client's current issue. Anemia does not directly relate to acute onset back pain. While diazepam, a benzodiazepine, has the potential to increase the risk for falls, it would not explain the client's severe pain after a minor fall.

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." 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

A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process?

"It will get better and worse again." The client demonstrates understanding of rheumatoid arthritis when expressing that it's an unpredictable disease characterized by periods of exacerbation and remission. There's no cure for rheumatoid arthritis, but symptoms can be managed. Surgery may be indicated in some cases.

A nurse is administering an IV antineoplastic agent when the client says, "My arm is burning by the IV site." What should the nurse do first?

Stop infusing the medication. Antineoplastic agents can cause severe tissue damage if they extravasate; therefore, the nurse should immediately stop the infusion. The correct dose should be verified before starting the infusion. After stopping the infusion, the nurse should notify the health care provider. If extravasation has occurred, it may be appropriate to apply ice packs to the site. Ice packs cause desired vasoconstriction; warm, moist packs cause vasodilation. Ice packs should not remain in place for more than 15 to 20 minutes because rebound vasodilation can occur; the ice packs are removed for a short time and then reapplied as needed.

When a client is diagnosed with aplastic anemia, the nurse should assess the client for changes in which physiologic functions?

bleeding tendencies Aplastic anemia decreases the bone marrow production of RBCs, white blood cells, and platelets. The client is at risk for bruising and bleeding tendencies. A change in the client's intake and output is important, but assessment for the potential for bleeding takes priority. Change in the peripheral nervous system is a priority problem specific to clients with vitamin B12 deficiency. Change in bowel function is not associated with aplastic anemia.

The nurse is teaching a client about preventing toxic shock syndrome (TSS). Which action is a risk factor for toxic shock syndrome?

using only tampons at night Risk factors for TSS include the use of tampons at night, when the tampon would be in place for 7 to 9 hours. TSS can occur in other situations, but it is commonly associated with women during menses, particularly women who use tampons. The longer the tampon is left in place, the greater the risk for TSS. Changing tampons every 3 hours or more frequently, avoiding use of deodorized tampons, and alternating tampons with sanitary pads are actions that decrease the risk of TSS.

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 The client's HIV status is irrelevant to the application of standard precautions, and the client should not be treated differently becuase 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 teaching a client with rheumatoid arthritis about how to manage the fatigue associated with this disease. Which statement by the client indicates she understands how to manage the fatigue?

"I schedule afternoon rest periods for myself in addition to sleeping 10 hours every night." Regularly scheduled rest periods during the day along with 8 to 10 hours of sleep at night helps relieve the fatigue, pain, and stiffness associated with rheumatoid arthritis. Even with mild rheumatoid arthritis, the client may find it difficult to perform activities of daily living without some rest periods. Spending 1 day a week in bed to relieve fatigue does not adequately manage the disease. The client must recognize the need for rest before feeling exhausted because overexertion can cause exacerbations. In addition, prolonged periods of inactivity can increase joint stiffness and pain. Getting up early to do household chores before the children are awake does not allow for adequate rest.

A client with iron-deficiency anemia is prescribed liquid iron supplements. The nurse evaluates the client's understanding of how to take this drug. Which statement indicates the client has adequate knowledge?

"I will dilute the medication and drink it with a straw." Liquid iron supplements should be diluted and taken through a straw to help decrease the likelihood of staining the teeth.Iron causes constipation, not diarrhea.It is normal for the client's stools to become dark during iron therapy.Iron does not cause bleeding gums.

A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?

"I won't donate blood, because I don't want to get AIDS." HIV is transmitted through infected blood, semen, and certain other body fluids, but it cannot be transmitted through water. Although a transfusion with infected blood may cause HIV infection in the recipient, a person cannot become infected by donating blood. Although the risk of contracting HIV is much higher for IV drug use that involves sharing needles, any substance abuse can alter decision-making abilities and is associated with high-risk sexual behaviors that increase the risk for contracting all sexually transmitted infections, including HIV.

A client with chronic progressive multiple sclerosis is learning to use a walker. What instruction will best ensure the client's safety?

"Place the walker directly in front of you and step into it as you move it forward." When the client places the walker directly in front of them, they create a stable base for forward movement and reduces the likelihood of falls. The client shouldn't set the back leg down first because this creates an unstable base that could lead to a fall. The client should firmly grip the side bars; doing so provides a more stable base of support than gripping the front bar. The nurse shouldn't suggest that the client use a walker with wheels. Only a physician or physical therapist may order a walker with wheels.

A family member of a client who is human immunodeficiency virus (HIV) positive is concerned about the possibility of also being HIV positive. What is the best response by the nurse?

"What's your understanding about how HIV is transmitted?" The nurse begins by establishing what the family member knows about the transmission of HIV. The family member is not asking about the client's medical condition, so there is no privacy concern. The principal method of contracting HIV is through needlestick injuries or blood contamination from an infected client. However, while it is important that the person know that administering care measures with usual precautions does not result in transmission, the nurse should not dismiss the client's concerns by merely saying not to worry.

A parent asks the nurse if a child's iron deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which principle?

Children with iron deficiency anemia are more susceptible to infection than are other children. Children with iron deficiency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis.

The nurse is caring for a client being discharged following kidney transplantation. The client is ordered mofetil to prevent organ rejection. Which nursing instruction is essential regarding medication use?

Contact the health care provider at first signs of an infection. Mofetil is an organ rejection medication that diminishes the body's ability to identify and eliminate pathogens (immunosuppressant). Identifying symptoms of infection at an early state is helpful in treating the infection. This medication is administered on an empty stomach. Typically, capsules would not be opened dispensing medication at one time. Antacids may decrease the absorption of the medication.

The parent brings a child to the clinic after discharge from the hospital for Guillain-Barré syndrome. Which statement by the parent indicates that the discharge plan is being followed?

"I take her to the pool where she can exercise with other children." Developmentally appropriate activities and therapeutic play should be used as rehabilitation modalities. Taking the child to the pool to exercise with other children indicates that the child is participating in exercise as well as engaging with other children, thus fostering development. Arguing with the sister does not address the discharge plan. Inappropriate rewards or threats should not be used to coerce a child into compliance. Although the mother is attempting to comply with the discharge plan, bribery is an inappropriate technique to foster compliance. Missing therapy sessions delays recovery. The parents need to help set the child's schedule to ensure that she gets adequate rest to be able to follow her treatment plan.

A nurse is caring for a client receiving radiation for Hodgkin's lymphoma who begins to exhibit confusion. Upon further assessment, the nurse notes that the client has warm, flushed, dry skin; a heart rate of 110 beats per minute; and a temperature of 101.8° F (38.8° C). Which is the nurse's next best action?

Notify the healthcare provider. The client is exhibiting signs and symptoms of sepsis and must be treated immediately. A neurological exam is not warranted and is time consuming at this point. A code is not necessary, as there is no indication that the client is pulseless or not breathing. The high Fowler's position will not change the outcome.

A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that the client has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?

Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI These are all appropriate nursing diagnoses for the client with thrombocytopenia. However, the risk of cerebral and GI hemorrhage and hypotension pose the greatest risk to the physiological integrity of the client.

The nurse is administering packed red blood cells (PRBCs) to a client. What should the nurse do first?

Stay with the client during the first 15 minutes of infusion. The most likely time for a blood transfusion reaction to occur is during the first 15 minutes or first 50 ml of the infusion. If a blood transfusion reaction does occur, it is imperative to keep an established I.V. line so that medication can be administered to prevent or treat cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-gauge or larger needle; a peripherally inserted central catheter line is not recommended, in order to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer's solution and should be infused with only normal saline solution.

When assessing for signs of a blood transfusion reaction in a client with dark skin, what sign should the nurse assess?

diaphoresis The nurse should assess for signs of impending shock such as diaphoresis. The client would have hypotension, dysuria, and cool skin.

A client with disseminated intravascular coagulation develops clinical manifestations of microvascular thrombosis. The nurse should assess the client for:

focal ischemia. Clinical manifestations of microvascular thrombosis are those that represent a blockage of blood flow and oxygenation to the tissue that results in eventual death of the organ. Examples of microvascular thrombosis include acute respiratory distress syndrome, focal ischemia, superficial gangrene, oliguria, azotemia, cortical necrosis, acute ulceration, delirium, and coma. Hemoptysis, petechiae, and hematuria are signs of hemorrhage.

A client on the oncology floor requires a blood transfusion. The nurse ensures proper consent is obtained by taking what action?

ensuring client is aware of indications, risks, and alternatives to receiving blood products By definition, informed consent requires that clients are provided with information needed to make informed decisions about their health care. Although the nurse should witness the consent once the necessary information is provided, this witnessing of the client's signature is not the same as ensuring the client has the information needed to offer informed consent. Clients need information about their health care regardless of any religious beliefs. While policies can vary between jurisdications, the primary health care provider is not the only individual who can legally obtain consent.

A client takes prednisone, as ordered, for rheumatoid arthritis. During follow-up visits, the nurse should assess the client for common adverse reactions to this drug, such as

fluid retention and weight gain. 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 such as antipsychotics. Anorexia, abdominal cramps, and diarrhea are common adverse reactions to many drugs, but not to steroids.

A client's arterial blood gas values are as shown on the accompanying chart. These findings indicate which of the following acid-base imbalances?

Metabolic acidosis. The pH of 7.24 indicates that the client is acidotic. The carbon dioxide level is normal, but the HCO3- level is decreased. These findings indicate that the client is in metabolic acidosis.

A client is about to undergo bone marrow aspiration of the sternum. What should the nurse tell the client?

"You will feel a pulling type of discomfort for a few seconds." As the bone marrow is being aspirated, the client will feel a suction or pulling type of sensation or discomfort that lasts a few seconds. A systemic premedication may be given to decrease this discomfort. A small area over the sternum is cleaned with an antiseptic. It is unnecessary to paint the entire anterior chest. The local anesthetic is injected through the subcutaneous tissue to numb the tissue for the larger-bore needle that is used for aspiration and biopsy. After the needle is removed, pressure is held over the aspiration site for 5 to 10 minutes to achieve hemostasis. A small dressing is applied; a large pressure dressing, such as an Ace bandage, would restrict the expansion of the lungs and is not used.

The nurse is teaching the parents of a child with sickle cell disease. What information should the nurse give the family on how to prevent sickle cell crisis?

Drink at least 2 quarts (2.3 liters) of fluids per day. Increasing fluid intake and being well hydrated will help prevent cell stasis in the small vessels. Restricting fluids causes stasis of red blood cells and promotes obstruction and increases the chance of sickling with hypoxia and pain to the part that is involved. Clients with sickle cell should avoid exercising in cool temperatures or swimming in cold water. Clients with sickle cell disease should stay away from others who have infections. When the spleen of a client who has sickle cell disease has become fibrotic and nonfunctional, the client is more susceptible to infections. Clients with sickle cell disease should not avoid physical activity as long as the client stays well hydrated.

A client with thrombocytopenia has developed a hemorrhage. The nurse should assess the client for which finding?

tachycardia The nurse should assess the client who is bleeding for tachycardia because the heart beats faster to compensate for decreased circulating volume and decreased numbers of oxygen-carrying red blood cells. The degree of cardiopulmonary distress and anemia will be related to the amount of hemorrhage that occurred and the period of time over which it occurred. Bradycardia is a late symptom of hemorrhage; it occurs after the client is no longer able to compromise and is debilitating further into shock. If bradycardia is left untreated, the client will die from cardiovascular collapse. Decreased PaCO2 is a late symptom of hemorrhage, after transport of oxygen to the tissue has been affected. A narrowed pulse pressure is not an early sign of hemorrhage

The nurse is admitting a child who has been diagnosed with bacterial meningitis to the pediatric unit. The nurse should implement which type of isolation?

droplet precautions Bacterial meningitis is caused by one of three organisms, Haemophilus influenzae type b, Neisseria meningitidis, or Streptococcus pneumoniae. All three organisms may be transmitted through contact with respiratory droplets. These droplets are heavy and typically fall within 3 feet (91.4 cm) of the client. Droplet precautions require, in addition to standard (routine) precautions, that HCPs wear masks when coming into close contact with the client. Standard or routine precautions, previously referred to as universal precautions, are general measures used for all clients. Contact precautions are used when direct or indirect contact with the client causes disease transmission. Gowns and gloves are needed but not masks. Airborne precautions differ from droplet in that the particles are smaller and may stay suspended in the air for longer periods of time. These clients require negative pressure rooms, and all heath care workers must wear respirators.

The nurse is evaluating the laboratory results of a client who was recently admitted to the hospital. Which result indicates the presence of inflammation?

leukocytosis Leukocytosis, an increased white blood cell count, indicates the presence of inflammation, infection, or a leukemia process. In inflammation and infection, the client's sedimentation rate is increased. Thrombocytopenia, a platelet deficiency, occurs in the client with leukemia, immunocompromised client, client with aplastic anemia, or client with other conditions. Erythrocytosis, an elevation of the red blood cell count, occurs in polycythemia vera.

The nurse admits a 1-year-old child to the hospital with the diagnosis of sickle cell crisis. The nurse explains to the parents that which condition leads to local tissue damage during a sickle cell crisis?

obstruction to circulation Characteristic sickle cells tend to cause "log jams" in capillaries. This results in poor circulation to local tissues, leading to ischemia and necrosis. The basic defect in sickle cell disease is an abnormality in the structure of the red blood cells. The erythrocytes are sickle-shaped, rough in texture, and rigid. Sickle cell disease is an inherited disease, not an autoimmune reaction. Elevated serum bilirubin concentrations are associated with jaundice, not sickle cell disease.

The nurse assesses the mouth and oral cavity of a client with human immunodeficiency virus (HIV) infection because the most common opportunistic infection initially presents with which symptom?

oral candidiasis The most common opportunistic infection in HIV infection initially presents as oral candidiasis, or thrush. The client with HIV should always have an oral assessment. HSV and CMV are opportunistic infections that present later in acquired immunodeficiency syndrome. Aphthous stomatitis, or recurrent canker sores, is not an opportunistic infection, although the sores are thought to occur more often when the client is under stress.

The nurse should assess a client for which complications associated with disseminated intravascular coagulation (DIC)?

pulmonary embolism Pulmonary embolism is an indication of intravascular clotting due to the fact that platelets have been significantly decreased and there is clotting and bleeding. Low prothrombin levels will also show that there is a delay in clotting, so the person will bleed for a longer time. The other conditions are not associated with DIC.

The daily white blood cell (WBC) count in a client with aplastic anemia drops overnight from 3,900 to 2,900/µl (3.9 to 2.9 X 109/L). Which is the appropriate nursing intervention?

Call the primary care provider, and request that the client be placed in reverse isolation The client will need a prescription from the HCP to be placed in reverse (protective) isolation because the normal defenses are ineffective and place the client at risk for infection (leukopenia, less than 5,000 cells/?L [5 × 109/L]). The faster the decrease in WBCs, the greater the bone marrow suppression, and the more susceptible the client is to infection from not only pathogenic but nonpathogenic organisms. The client will continue to be monitored, the laboratory may be called, and the report will be placed on the chart, but protection of the client must be instituted immediately.

A nurse in the infection prevention and control program is conducting an assessment of infection control practices. The nurse is evaluating the infection control actions taken on the unit for a client with a decreased white blood cell count. Which infection control practice does the nurse consider most important for this client?

adhering diligently to aseptic technique The client in this scenario is neutropenic, which places the client at risk for contracting an infection. All measures of aseptic technique must be used to protect the client. The other options do not provide complete protection for the client.

The nurse is teaching the client with a platelet disorder about signs of bleeding. What statement from the client indicates the client has understood the teaching?

"Ecchymoses are large, purple skin bruises." Large, purplish skin lesions caused by hemorrhage are called ecchymoses. Small, flat, red pinpoint lesions are petechiae. Numerous petechiae result in a reddish, bruised appearance called purpura. An abrasion is a wound caused by scraping.

The nurse is assessing a client with dark skin who has early signs of iron deficiency anemia. Which is the expected color of this client's skin?

yellowish-brown One of the early signs of iron deficiency anemia in a client of Vietnamese descent with dark skin is yellowish-brown skin tones. The nurse can assess for petechiae or jaundice, which may be observed in the conjunctiva or buccal mucosa.

Allopurinol is prescribed for a client who has chronic gout. Which comment indicates that the client understands how to take the allopurinol?

"I should drink plenty of fluids when taking allopurinol." It is important that the client force fluids to 3,000 mL/day to avoid the development of renal calculi when taking allopurinol. Allopurinol must be taken consistently to be effective in the treatment of gout. The drug should be taken after meals to avoid gastrointestinal distress. Although the client can take aspirin when taking allopurinol, both drugs can cause gastrointestinal irritation, and the practice is not recommended if the client is sensitive to the medications.

A client with allergic rhinitis asks the nurse what to do to decrease rhinorrhea. Which instruction would be appropriate for the nurse to give the client?

"Keep a diary of when your symptoms occur. This can help you identify what precipitates your attacks." It is important for clients with allergic rhinitis to determine the precipitating factors so that they can be avoided. Keeping a diary can help identify these triggers. Nasal decongestant sprays should not be used regularly because they can cause a rebound effect. Antibiotics are not appropriate for allergic rhinitis because an infection is not present. Increasing activity will not control the client's symptoms; in fact, walking outdoors may increase them if the client is allergic to pollen.

A client with acquired immunodeficiency syndrome is admitted with Pneumocystis jirovecipneumonia. The client begins to cry and says, "My friends and relatives have stopped visiting and calling." What is the nurse's best response?

"That sounds very difficult. How are you coping with this?" The nurse should acknowledge hearing the client's concern and explore it further. Offering unsolicited adivce or solutions (speak to the friends and relatives, join a support group) cuts the exploration of the client's feelings short. While the nurse could explore who the client has as supports, this does not facilitate the exploration of the sadness the client currently is expressing.

A nurse notes the following laboratory values for a client receiving chemotherapy: white blood cell count 6000/µL, red blood cell count (RBC) 3.7 million cells/cm3, hematocrit 35%, platelet count 80,000 mm3. Which order would the nurse question?

rectal temperatures every 4 hours The platelet count indicated that the client is a risk for bleeding. The low RBC can cause fatigue, so the activity order is appropriate. The hematocrit is reflective of the low RBC count. The white blood cell count is normal, so a semiprivate room or restricted diet is acceptable.

A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the heatlchare provider (HCP) immediately?

urine output of 20 ml/hour Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate notification of the HCP. A serum potassium level of 4.9 mEq/L and a temperature of 99.2°F are normal assessment findings. Although the blood pressure is a bit elevated, this is not a reason to notify the HCP. The nurse knows that hypotension rather than hypertension poses a more serious risk for the client because hypoperfusion of the kidney can complicate recovery.

What should the nurse teach the client with neutropenia to avoid?

using suppositories or enemas The neutropenic client is at risk for infection, especially bacterial infection of the respiratory and gastrointestinal tracts. Breaks in the mucous membranes, such as those that could be caused by the insertion of a suppository or enema tube, would be a break in the first line of the body's defense and a direct port of entry for infection. The client with neutropenia is encouraged to wear a HEPA filter mask and to use an incentive spirometer for pulmonary hygiene. The client needs to know the importance of completing meticulous total body hygiene daily, including perianal care after every bowel movement, to decrease the flora at normal body orifices. The client also needs to know the importance of performing oral care after every meal and every 4 hours while the client is awake to decrease the bacterial buildup in the oropharynx.

A client with rheumatoid arthritis tells the nurse, "I know it's important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which response by the nurse would be most appropriate?

"Take a warm tub bath or shower before exercising. This may help with your discomfort." Superficial heat applications, such as tub baths, showers, and warm compresses, can be helpful in relieving pain and stiffness. Exercises can be performed more comfortably and more effectively after heat applications. The client with rheumatoid arthritis must balance rest with exercise every day, not every other day. Typically, large doses of analgesics, which can lead to hepatotoxic effects, are not necessary. Learning to cope with the pain by refocusing is inappropriate.

When starting the client's intravenous infusion line, the nurse applies a tourniquet and selects the site for inserting the needle. When should the nurse remove the tourniquet?

as soon as the needle is in the vein When starting an IV infusion, the nurse should remove the tourniquet as soon as the needle is in the vein. Until then, the tourniquet keeps the vein distended so that it is more visible and easier to enter.Leaving the tourniquet in place longer can impair circulation.

The nurse is removing personal protective equipment. In which order (first to last) should the nurse remove the equipment? All options must be used.

gloves goggles gown mask The nurse should first remove the gloves, followed by the goggles and gown. Once outside the client's room, the nurse should remove the mask.

A client with pernicious anemia asks why she must take vitamin B12 injections forever. Which is the nurse's best response?

"The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient amounts of a factor that allows the vitamin to be absorbed." Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine. The stomach is producing enough acid, there is not an excessive excretion of the vitamin, and there is not a rapid production of red blood cells in this condition.

A client with severe arthritis has been receiving maintenance therapy of prednisone 10 mg/day for the past 6 weeks. The nurse should instruct the client to immediately report which symptom?

respiratory infection Clients receiving chronic steroid therapy can become immunosuppressed and are prone to infections. Signs of infection can also be masked with prednisone. Signs and symptoms of infection should be reported immediately. Joint pain, constipation, and joint swelling are not related to the adverse effects of steroid therapy.

A nurse is caring for a client with human immunodeficiency virus (HIV). To determine the effectiveness of treatment the nurse expects the physician to order:

quantification of T-lymphocytes. Quantification of T-lymphocytes is used to monitor the effectiveness of treatment for HIV. E-rosette immunofluorescence is used to detect viruses in general; it doesn't confirm HIV infection. The ELISA test detects HIV antibody particles but may yield inaccurate results; a positive ELISA result must be confirmed by the Western blot test. The Western blot test — electrophoresis of antibody proteins — detects HIV antibodies when used in conjunction with the ELISA. It isn't specific when used alone and doesn't monitor the effectiveness of treatment.

A client develops thrombocytopenia during chemotherapy. The nurse assesses the client for what signs of bleeding? Select all that apply.

shortness of breath tachycardia difficulty speaking Acute blood loss may manifest in different ways depending on where the bleeding is taking place. Large volume blood loss often occurs in the gastrointestinal tract. This can cause acute onset anemia, which will create symptoms such as dyspnea and tachycardia due to decreased oxygen carrying capacity from loss of hemoglobin. This type of bleeding may result in hematemesis or melena, and a drop in RBC and hemoglobin level would be expected in laboratory findings. However, if the bleeding were to occur intracranially, very little blood loss will occur. Instead, increase in intracranial pressure will cause acute neurological changes, such as difficulty speaking. Anemia will not result in either cyanosis or a drop in oxygen saturation. In anemia, the oxygen carrying capacity is diminished but each hemoglobin molecule will still be fully saturated with oxygen, therefore the client's oxygen saturation will be normal. Cyanosis occurs because hemoglobin in the arterial circulation has not been oxygenated due to a gas exchange issue (i.e., a respiratory problem), which anemia is not. In fact, a client with a low hemoglobin level is less likely to experience cyanosis for this reason.

A nurse is developing a care plan for a client with disseminated intravascular coagulation (DIC). Which nursing intervention should the nurse include?

Place a pressure-reducing mattress on the client's bed. A client with DIC is at risk for Impaired skin integrity related to bleeding or ischemia. The nurse should place the client on a pressure-reducing mattress and perform skin care every 2 hours. The nurse should avoid administering any medication that decreases platelet function, such as aspirin. The nurse should perform mouth care using sponge swabs and baking soda solution, not lemon-glycerin swabs, because lemon-glycerin swabs can dry the oral mucosa, which may lead to bleeding. I.M. injections should be avoided in clients with DIC because of the potential for bleeding.

A client who is sexually active asks the nurse about using PreExposure Prophylaxis (PrEP) for HIV. The nurse should tell the client the drug, a combination of 300 milligrams tenofovir disoproxil fumarate and 200 milligrams emtricitabine (TDF/FTC) can be used for which group of people who are at risk for becoming infected with HIV?

anyone who is in an ongoing sexual relationship with an HIV-infected partner PrEP is primarily available to anyone who is in an ongoing sexual relationship with an HIV-infected partner. Others at risk, such as those who are having sex with partners who are at risk for HIV such as drug users or who are themselves sharing equipment with people who are at risk for HIV, may also receive PReP. The drug is not used for people who do not use condoms, have untreated sexually transmitted diseases, or a compromised immune system.

After teaching the client with rheumatoid arthritis about measures to conserve energy in activities of daily living involving the small joints, which activity observed by the nurse indicates the need for additional teaching?

carrying a laundry basket with clinched fingers and fists Carrying a laundry basket with clinched fingers and fists is not an example of conserving energy of small joints. The laundry basket should be held with both hands opened as wide as possible and with outstretched arms so that pressure is not placed on the small joints of the fingers. When rising from a chair, the palms should be used instead of the fingers so as to distribute weight over the larger area of the palms. Holding packages close to the body provides greater support to the shoulder, elbow, and wrist joints because muscles of the arms and hands are used to stabilize the weight against the body. This decreases the stress and weight or pull on small joints such as the fingers. Objects can be slid with the palm of the hand, which distributes weight over the larger area of the palms instead of stressing the small joints of the fingers to pick up the weight of the object to move it to another place.

A client receiving a blood transfusion experiences an acute hemolytic reaction. Which nursing intervention is the most important?

Stop the transfusion, infuse normal saline solution, and call the physician. When a transfusion reaction occurs, the transfusion should be immediately stopped, normal saline solution should be infused to maintain venous access, and the physician and blood bank should be notified immediately. Other nursing actions include saving the blood bag and tubing, rechecking the blood type and identification numbers on the blood tags, monitoring vital signs, obtaining necessary laboratory blood and urine samples, providing proper documentation, and monitoring and treating for shock. Because they can cause red blood cell hemolysis, dextrose solutions should not be infused with blood products. Antihistamines are administered for a mild allergic reaction, not a hemolytic reaction.

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 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.

A client is taking large doses of aspirin daily to treat rheumatoid arthritis. The nurse should instruct the client to tell the health care provider (HCP) when having:

tinnitus. Tinnitus or ringing in the ears is a sign of aspirin toxicity and should be reported. Clients should be instructed to take aspirin as prescribed and to avoid overdosage. Gastrointestinal symptoms associated with aspirin include nausea, heartburn, and epigastric discomfort caused by gastric irritation. Abdominal cramps, rash, and hypotension are not related to aspirin therapy.

A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to

sit upright, leaning slightly forward. Sitting upright and leaning slightly forward avoids increasing vascular pressure in the nose and helps the client avoid aspirating blood. Lying supine won't prevent aspiration of the blood. Nose blowing can dislodge any clotting that has occurred. Bending at the waist increases vascular pressure in the nose and promotes bleeding rather than halting it.