Immune and Hematologic Disorders
A client undergoing antineoplastic therapy is prescribed subcutaneous epoetin. What indicates to the nurse that the drug has been effective? Biopsies no longer show malignancy. Hemoglobin levels rise. Nausea and vomiting stop. A scan shows tumor shrinkage.
Hemoglobin levels rise.
The nurse in the emergency department is caring for a 22-year-old male client who received an mRNA COVID vaccination 2 days ago and now reports a sore arm at the injection site, fatigue, chest pain, headache, and chills. An examination by the nurse reveals a pericardial friction rub, weak peripheral pulses, jugular vein distention, strong hand grasps and leg strength bilaterally, clear breath sounds, and no redness, warmth, or pain in the calves. Vital signs: temperature, 101.4°F (38.6°C); heart rate, 104 beats/min; respiratory rate, 24 breaths/min; blood pressure, 128/64 mm Hg; oxygen saturation 96% on room air. Complete the sentence: The nurse anticipates that this client is experiencing ............ (myocarditis, thromboembolism, or Guillain-Barre syndrome) as evidenced by ............ (breath sounds, muscle strength assessment, or cardiac assessment) and ............ (fever, fatigue, calf assessment)
The nurse anticipates that this client is experiencing myocarditis as evidenced by cardiac assessment and fever
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 may cure the virus. But if you decide against it, I'll tell the physician that you don't want your partner to have the procedure." "The implant won't cure the virus, but it may protect your partner's sight. Just because your partner has dementia doesn't mean your partner shouldn't be given the opportunity to see." "The implant may cu
"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."
A pregnant client who developed deep vein thrombosis (DVT) in her right leg is receiving heparin I.V. on the medical floor. Physical therapy is ordered to maintain her mobility and prevent additional DVT. A nursing assistant working on the medical unit helps the client with bathing, range-of-motion exercises, and personal care. Which collaborative multidisciplinary considerations should the care plan address? The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include sequential compression device application and strict bed rest. The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising. The client is at risk for developing another DVT; therefore, the care plan should include reporting redness, tenderness, or edema in the other lower extremity. The client is pregnant and receiving I.V.
The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising.
The nurse is assessing a client for signs of a blood transfusion reaction. Which finding indicates the client is having a transfusion reaction? hypertension diaphoresis polyuria warm skin
diaphoresis
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? standard or routine precautions contact precautions airborne precautions droplet precautions
droplet precautions
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? weight gait hearing muscle mass
hearing
A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see? hypercalcemia hyperkalemia hypernatremia hypermagnesemia
hypercalcemia
A client presents to the community clinic with a viral infection and swollen lymph nodes. When assessing the lymph nodes of the head and neck, the nurse notes hard and irregular shaped nodes in the submandibular region. When documenting the site of the lymph nodes, which are the area of concern?
middle of jawline
The nurse is teaching a client about possible side effects when taking a diuretic. Which is an early indication that the client's serum potassium level is below normal? diarrhea sticky mucous membranes muscle cramps in the legs tingling in the fingers
muscle cramps in the legs
The nurse should assess a client for which complications associated with disseminated intravascular coagulation (DIC)? renal calculi congestive heart failure pulmonary embolism septic shock
pulmonary embolism
A client has extreme fatigue and is malnourished, and laboratory tests reveal a hemoglobin level of 8.5 g/dL (85 g/L). The nurse should specifically ask the client about the intake of food low in which nutrients? vitamins A, E, and C vitamins B6 and B12, folate, iron, and copper thiamine, riboflavin, and niacin vitamins A and B
vitamins B6 and B12, folate, iron, and copper
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 (HCP) let me try that?" Which response by the nurse would be most appropriate? "It's the HCP's prerogative to decide how to treat you. They have chosen what is best for your situation." "Tell me more about your friend's arthritic condition. Maybe I can answer that question for you." "That drug is used for cases that are more advanced than yours. You're not eligible for this treatment now." "Every person is different. What works for one client may not always be effective for another."
"Every person is different. What works for one client may not always be effective for another."
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." "When it clears up, it will never come back." "I'll definitely need surgery for this." "It will never get any better than it is right now."
"It will get better and worse again."
A nurse is preparing to administer a unit of blood to a client with anemia. After removal of the blood from the refrigerator, the transfusion of the blood must be completed within: 1 hour. 2 hours. 4 hours. 6 hours.
4 hours.
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. O-negative blood to an O-positive client. O-positive blood to an A-positive client. B-positive blood to an AB-positive client.
A-positive blood to an A-negative client.
A client with acute lymphocytic leukemia is receiving vincristine. Prior to infusing the drug, the nurse administers diphenhydramine. What should the nurse tell the client about the purpose of taking diphenhydramine? Diphenhydramine promotes sleep while the vincristine is infusing. Diphenhydramine decreases the incidence of a reaction to the vincristine. Diphenhydramine potentiates the action of the vincristine. Diphenhydramine reduces anxiety associated with the vincristine infusion.
Diphenhydramine decreases the incidence of a reaction to the vincristine.
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. Apply ice to the biopsy site. Clean the skin with an antiseptic solution. Position the client in a side-lying position.
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.
The nurse is assessing a client who has aplastic anemia. Which finding indicates the client has physiologic changes as a result of the disease? bleeding tendencies decreased intake and output loss of peripheral sensation frequent diarrhea
bleeding tendencies
A nurse is caring for several clients on an oncology unit. Which client should the nurse see first? client who is on complete bed rest client with a white blood cell count of 2000 µL client receiving brachytherapy for prostate cancer client who is 2 days postoperative following a hemicolectomy
client with a white blood cell count of 2000 µL
The nurse is assessing a client with anemia. To plan nursing care, the nurse should focus the assessment on which sign or symptom? decreased salivation bradycardia cold intolerance nausea
cold intolerance
A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia? nights sweats, weight loss, and diarrhea dyspnea, tachycardia, and pallor nausea, vomiting, and anorexia itching, rash, and jaundice
dyspnea, tachycardia, and pallor
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? diphenhydramine epinephrine albuterol (salbutamol) prednisone
epinephrine
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 platelet count, red blood cell count, and hemoglobin thrombin time, fibrinogen, and hemoglobin level D-dimer, red blood cell count, and partial thromboplastin time
platelet count, prothrombin time, and partial thromboplastin time
A 25-year-old client taking hydroxychloroquine for rheumatoid arthritis reports difficulty seeing out of their left eye. What does this finding indicate? development of a cataract possible retinal degeneration part of the disease process a coincidental occurrence
possible retinal degeneration
A client with AIDS develops a fever, severe headache, and stiff neck and begins to vomit. Family members state they have noticed that the client does not seem to be as alert and oriented as before. What is the nurse's priority intervention? administering an antibiotic preparing the client for a lumbar puncture starting an I.V. protecting the client's airway
protecting the client's airway
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? semiprivate room regular diet activity as tolerated rectal temperatures every 4 hours
rectal temperatures every 4 hours
A client has been taking a decongestant for allergic rhinitis. Which finding suggests that the decongestant demonstrates maximum therapeutic effective? oral dryness increased tearing reduced sneezing headache improvement
reduced sneezing
After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first? Establish intravenous access. Administer epinephrine. Administer albuterol (salbutamol). Provide respiratory support with bag-valve mask.
Administer epinephrine.
A client with rheumatoid arthritis states, "I can't do my household chores without becoming tired. My knees hurt whenever I walk." Which goal for this client should take priority? Conserve energy. Adapt self-care skills. Develop coping skills. Employ a housekeeping service.
Conserve energy.
Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. What vital sign values most support the nurse's analysis? Blood pressure of 150/100 mm Hg and pulse of 130 beats per minute. Blood pressure of 150/100 mm Hg and pulse of 50 beats per minute. Blood pressure of 80/40 mm Hg and pulse of 50 beats per minute. Blood pressure of 80/40 mm Hg and pulse of 130 beats per minute.
Blood pressure of 80/40 mm Hg and pulse of 130 beats per minute.
The nurse is caring for a client who has a history of aplastic anemia. Which information from the nursing history indicates that the anemia is not being managed effectively? pallor of the skin and mucous membranes heart rate of 68 bpm, bounding pulse blood pressure of 146/90 mm Hg poor skin turgor
pallor of the skin and mucous membranes
A client newly diagnosed with acute lymphocytic leukemia has a right subclavian central venous catheter in place. The nurse who is caring for the client is teaching a graduate nurse about central venous catheter care. The nurse should instruct the graduate nurse to change the dressing when? Select all that apply. per hospital policy every 72 hours when the dressing is becoming loose when the dressing is soiled when the site is reddened
per hospital policy when the dressing is becoming loose when the dressing is soiled when the site is reddened
A client with the beta-thalassemia trait plans to marry a person of Italian ancestry who also has the trait. Which client statement indicates understanding of the teaching provided by the nurse? "We should never plan to have children." "I need to learn how to give myself vitamin B12 injections." "We'll need more genetic counseling in the future." "If my fiancé was of Middle Eastern descent, I wouldn't be worried about having children."
"We'll need more genetic counseling in the future."
The nurse is preparing to administer 500 mL of whole blood to a client. The blood is to be infused over 4 hours. The infusion tubing delivers 10 gtt/mL. How many drops of blood per minute must the nurse infuse to complete the infusion in 4 hours?
21 gtts/min
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? Prescribe an antidiarrheal medication. Collect a sample for stool culture and sensitivity. Collect stool sample for clostridioides difficile. Prescribe STAT intravenous fluid therapy.
Collect stool sample for clostridioides difficile.
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? Administer medication following breakfast daily. Contact the health care provider at first signs of an infection. Sprinkle the contents of the capsule on food. Administer the medication with an antacid to prevent stomach upset.
Contact the health care provider at first signs of an infection.
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 until my signs and symptoms disappear." "I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal." "I will receive parenteral vitamin B12 therapy monthly for 6 months to a year." "I will receive parenteral vitamin B12 therapy for the rest of my life."
"I will receive parenteral vitamin B12 therapy for the rest of my life."
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 you move the walker, set the back legs down first. Then step forward." "Maintain a firm grip on the front bar as you step into the walker." "Use a walker with wheels to help you move forward."
"Place the walker directly in front of you and step into it as you move it forward."
A client with acquired immunodeficiency syndrome is admitted with Pneumocystis jiroveci pneumonia. The client begins to cry and says, "My friends and relatives have stopped visiting and calling." What is the nurse's best response? "Have you tried speaking with them about how you feel?" "Would you like me to look for a support group you could join?" "That sounds very difficult. How are you coping with this?" "Who are your main supports when you are at home?"
"That sounds very difficult. How are you coping with this?"
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? Little is known about iron deficiency anemia and its relationship to infection in children. Children with iron deficiency anemia are more susceptible to infection than are other children. Children with iron deficiency anemia are less susceptible to infection than are other children. Children with iron deficiency anemia are equally as susceptible to infection as are other children.
Children with iron deficiency anemia are more susceptible to infection than are other children.
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? Activity intolerance Impaired tissue integrity Impaired oral mucous membranes Ineffective tissue perfusion: cerebral, cardiopulmonary, GI
Ineffective tissue perfusion: cerebral, cardiopulmonary, GI
A client with a suspected diagnosis of Hodgkin disease is to have a lymph node biopsy. What should the nurse make sure that personnel involved with the procedure do? Maintain sterile technique. Use a mask, gloves, and a gown when assisting with the procedure. Send the specimen to the laboratory when someone is available to take it. Ensure that all instruments used are placed in a sealed and labeled container.
Maintain sterile technique.
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 immunodeficiency syndrome (AIDS) phase of this infection? Engage in safer-sex practices at all times. Strictly adhere to antiviral medication therapy. Practice meticulous infection control. Maintain a generally healthy lifestyle.
Strictly adhere to antiviral medication therapy.
A client infected with human immunodeficiency virus (HIV) has a low CD4+ level. What intervention should the nurse implement? Increase nutritional protein with each meal. Request human granulocyte colony-stimulating factor to improve WBC production. Place the client in reverse isolation. Provide antibiotics as per order.
Place the client in reverse isolation.
A client was recently discharged with a peripherally inserted central catheter, and the home care nurse begins teaching him how to care for the catheter. The client states, "I'm so confused. The nurses in the hospital started to show me how to care for this catheter, but I don't think I'll be able to keep it all straight." Which response by the nurse is most appropriate? "Don't worry. That's why your physician ordered home care for you. If you aren't able to learn how to care for the catheter, we can do it for you." "We'll make sure that you feel comfortable caring for your catheter. Can you show me what the nurses in the hospital showed you?" "Community nurses are very busy, so you'll need to learn quickly." "Don't underestimate yourself; you'll know how to care for your catheter in no time."
"We'll make sure that you feel comfortable caring for your catheter. Can you show me what the nurses in the hospital showed you?"
A client had an anaphylactic reaction and requires intravenous fluids. The order calls for 1000 mL of normal saline to be administered over 8 hours using an infusion set with a drop factor of 10 gtt/mL. How many drops per minute should the client receive? Record the answer using a whole number.
21 drops/min
A sexually active client asks the nurse about using pre-exposure prophylaxis (PrEP) for HIV. The nurse should tell the client the drug, a combination of 300 mg tenofovir disoproxil fumarate and 200 mg emtricitabine (TDF/FTC) can be used for which group of people who are at risk for becoming infected with human immunodeficiency virus (HIV)? anyone who is in an ongoing sexual relationship with an HIV-infected partner people who do not use condoms when in a sexual relationship persons with a sexually transmitted disease that is not being treated anyone with a compromised immune system
anyone who is in an ongoing sexual relationship with an HIV-infected partner
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? "I can't discuss the client's HIV status without their permission." "What's your understanding about how HIV is transmitted?" "Don't worry. You can't contract HIV through casual contact." "Would you like to discuss your concerns with the doctor?"
"What's your understanding about how HIV is transmitted?"
A client is about to undergo bone marrow aspiration of the sternum. What should the nurse tell the client? "You may feel a solution being wiped over your entire front from your neck down to your navel and out to your shoulders." "You will not feel the local anesthetic being applied because it will be sprayed on." "You will feel a pulling type of discomfort for a few seconds." "After the needle is removed, you will feel a bandage being applied around your chest."
"You will feel a pulling type of discomfort for a few seconds."
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? Encourage the client to increase their fluid intake. Cleanse the incision site with soap and water. Place an absorbent dressing over the incision. Notify the health care provider (HCP).
Notify the health care provider (HCP).
A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client? Pallor, bradycardia, and reduced pulse pressure Pallor, tachycardia, and a sore tongue Sore tongue, dyspnea, and weight gain Angina pectoris, double vision, and anorexia
Pallor, tachycardia, and a sore tongue
A client who had a splenectomy is being discharged. What should the nurse teach the client to do? Refrain from driving a car for 6 weeks. Alternate rest and activity. Make an appointment for the staples to be removed. Report early signs of infection.
Report early signs of infection.
A client with a pleural effusion has a diagnostic thoracentesis. The nurse notifies the healthcare provider immediately upon discovering what assessment finding? blood present on dressing asymmetrical chest expansion a blood pressure of 155/95 mmHg heart rate of 55 beat/minute
asymmetrical chest expansion
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." "The health care provider will prescribe corticosteroid cream." "The wound will need to be closed with sutures." "You'll need to be tested for rabies."
"You'll need an injection of tetanus toxoid."
A client with thrombocytopenia has just had a bone marrow aspirate performed to monitor for treatment effectiveness. Which nursing intervention takes priority? cleaning the puncture site and applying a pressure dressing cleaning the puncture site and applying a sterile dressing applying pressure to the puncture site for a full 10 minutes monitoring the client's vital signs for signs and symptoms of infection
applying pressure to the puncture site for a full 10 minutes
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? no priming needed since blood products must be infused alone per current guidelines dextrose 5% in water as this is considered an isotonic solution lactated Ringer's solution as this is considered an isotonic solution normal saline solution as this is considered an isotonic solution
normal saline solution as this is considered an isotonic solution
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? Tay-Sachs cells. Sarcoidosis cells. Reed-Sternberg cells. Duchenne's cells.
Reed-Sternberg cells.
A nurse is caring for a client who is having an allergic reaction to a blood transfusion. In what order from first to last should the nurse provide care for this client? All options must be used. Send the blood bag and blood slip to the blood bank. Administer an antihistamine as directed. Keep the vein open with normal saline solution. Stop the transfusion.
Stop the transfusion. Keep the vein open with normal saline solution. Administer an antihistamine as directed. Send the blood bag and blood slip to the blood bank.
The nurse is teaching the client who is undergoing induction therapy for leukemia. The nurse realizes the client needs additional instruction when the client makes which statement? "I will have to pace my activities with rest periods." "I cannot wait to get home to my cat!" "I will use a warm saline gargle instead of brushing my teeth." "I must report a temperature of 100°F (37.7°C)."
"I cannot wait to get home to my cat!"
The nurse is administering an intravenous (IV) infusion of packed red blood cells and normal saline solution to a client who is in hemorrhagic shock. Which is a priority for the nurse to assess for this client? fluid balance anaphylactic reaction pain altered level of consciousness
anaphylactic reaction
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? Avoid using oil-based lotions on the client's skin. Ensure client's roommate does not have an indwelling latex urinary catheter. Place latex-free, powder-free gloves at client's bedside. Place client in private room with clear signage about allergy.
Place latex-free, powder-free gloves at client's bedside.
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? Ensure PRN suppository or enemas are prescribed to prevent fecal impaction. Place the client in a private, negative-pressure isolation room. Request regularly scheduled antipyretic medication be prescribed. Place sign on client's door reminding all persons to wash hands prior to entering.
Place sign on client's door reminding all persons to wash hands prior to entering.
A nurse is providing care for a client with progressive systemic sclerosis. For a client with this disease, the nurse is most likely to formulate which nursing diagnosis? Risk for impaired skin integrity Constipation Ineffective thermoregulation Risk for imbalanced nutrition: More than body requirements
Risk for impaired skin integrity
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority? Bathing or hygiene self-care deficit Ineffective cerebral tissue perfusion Complicated grieving Risk for injury
Risk for injury
Allopurinol is prescribed for a client who has chronic gout. Which comment indicates that the client understands how to take the allopurinol? "I'll take the medication whenever my joints hurt." "I must take this drug on an empty stomach." "I should drink plenty of fluids when taking allopurinol." "I shouldn't take aspirin when taking allopurinol."
"I should drink plenty of fluids when taking allopurinol."
A client with granulocytopenia has many visitors. What is the most important thing the nurse should tell the visitors to do to prevent infection? Visit only if they do not have a cold. Wash their hands. Leave the children at home. Avoid kissing the client.
Wash their hands.
The nurse is developing a plan of care for a client who has joint stiffness because of rheumatoid arthritis. Which measure will be the most effective in relieving stiffness? a warm shower before performing activities of daily living aspirin after activity to decrease inflammation a 4.5-kg (10-lb) weight loss to limit stress on joints cold compresses to joints for 30 minutes to relieve stiffness
a warm shower before performing activities of daily living
Which laboratory test should the nurse monitor while the client is receiving heparin therapy? international normalized ratio (INR) activated partial thromboplastin time (APTT) prothrombin time (PT) thrombin time
activated partial thromboplastin time (APTT)
The nurse reviews test results that were completed to determine if a client has systemic lupus erythematosus (SLE). Which test does the nurse document as evidence that the client may have an SLE diagnosis? increased total serum complement levels negative antinuclear antibody test negative lupus erythematosus cell test elevated anti-double stranded deoxyribonucleic acid (dsDNA) test
elevated anti-double stranded deoxyribonucleic acid (dsDNA) test
A nurse preparing to discharge a child with leukemia observes a family member who has a cold sharing a meal with the child. How should the nurse approach the situation? Instruct family members not share food because it isn't healthful. Offer a face mask to the person with the cold and use this as an opportunity for further teaching. Tell family members to be careful to avoid the child if they're sick. Post isolation signs on the child's door and carefully assess the health status of all visitors.
Offer a face mask to the person with the cold and use this as an opportunity for further teaching.
The wife of a client with end-stage acquired immunodeficiency syndrome (AIDS) is caring for her husband at home. The hematologist recommends hospice care and the couple agrees. During the initial admission visit, the hospice nurse provides information to the client and his family about an advance directive. During the next day's visit, the client states that since he and his wife filled out the advance directive form, he feels abandoned by his physician. Which statement by the hospice nurse best addresses the client's concerns? "Your physician will continue to care for you. The advance directive simply puts in writing the care you want, so the physician will be able to provide it if you can't tell him yourself." "You don't need to feel that way. Your physician is required by law to sign your orders and the hospice nurses will be contacting him with updates on your condition." "Many people first feel that way when
"Your physician will continue to care for you. The advance directive simply puts in writing the care you want, so the physician will be able to provide it if you can't tell him yourself."
The nurse is administering packed red blood cells (PRBCs) to a client. What should the nurse do first? Discontinue the intravenous (IV) catheter if a blood transfusion reaction occurs. Administer the PRBCs through a percutaneously inserted central catheter line with a 20-gauge needle. Flush PRBCs with 5% dextrose and 0.45% normal saline solution. Stay with the client during the first 15 minutes of infusion.
Stay with the client during the first 15 minutes of infusion.
An RN preceptor is assisting a new graduate to access a port-a-cath with a Huber needle. Which action by the new graduate would require intervention by the RN preceptor? inserting the needle at 90 degrees through the skin wearing a surgical mask during the procedure wearing sterile gloves during the procedure rotating the needle immediately after access
rotating the needle immediately after access
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: abdominal cramps. tinnitus. rash. low blood pressure.
tinnitus.
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? It will take several months to notice an improvement. Folic acid should be taken on an empty stomach. Iron supplements are contraindicated with folic acid supplementation. Oral contraceptive use, pregnancy, and lactation increase daily requirements.
Oral contraceptive use, pregnancy, and lactation increase daily requirements.
A client receiving a blood transfusion experiences an acute hemolytic reaction. Which nursing intervention is the most important? Assess the temperature, blood pressure, and check for blood in the urine. Then stop the transfusion. Slow the transfusion and monitor the client's vital signs. Stop the transfusion, notify the blood bank, and administer antihistamines. Stop the transfusion, infuse normal saline solution, and call the physician.
Stop the transfusion, infuse normal saline solution, and call the physician.
A client with aplastic anemia is instructed to eat foods rich in iron. The nurse should instruct the client to include which food in the diet to increase iron intake? fresh fruits cheese dark green leafy vegetables chicken breasts
dark green leafy vegetables
A home care nurse is making the initial home visit to a client with lung cancer who had a peripherally inserted central catheter placed during hospitalization for an upper respiratory infection. During the visit, the nurse must administer an antibiotic, teach the client how to care for the catheter, and provide information about when to notify the home care agency and physician. When the nurse arrives at the client's home, the client's face is flushed and he complains of feeling tired. Which actions should the nurse take first? Call the physician to update him on the client's condition and administer the antibiotic. Obtain the client's vital signs and then administer the antibiotic. Obtain the client's vital signs and assess breath sounds. Administer the antibiotic, obtain vital signs, assess breath sounds, and then begin the teaching session.
Obtain the client's vital signs and assess breath sounds.
