T3U2 Hema & Lymph
A public health nurse is planning community teaching for a group of older adults regarding aging and hematological conditions. What condition will the nurse identify as most common among this population?
Correct response: Anemia Explanation: Anemia is the most common hematological condition in older adults, particularly those admitted to hospitals and long-term care facilities.
The nurse is educating a client about iron supplements. The nurse teaches that what vitamin enhances the absorption of iron?
Correct response: C Explanation: Vitamin C facilitates the absorption of iron. Therefore, iron supplements should be taken with a glass of orange juice or a vitamin C tablet to maximize absorption.
A patient with end-stage kidney disease (ESKD) has developed anemia. What laboratory finding does the nurse understand to be significant in this stage of anemia?
Correct response: Creatinine level of 6 mg/100 mL Explanation: The degree of anemia in patients with end-stage renal disease varies greatly; however, in general, patients do not become significantly anemic until the serum creatinine level exceeds 3 mg/100 mL.
The nurse is reviewing a client's laboratory results and notes that her hemoglobin level is 15 g/dL. What action should the nurse take next?
Correct response: Document the finding as normal. Explanation: The nurse should document the finding as normal. In adults, the normal amount of hemoglobin is 12 to 17.4 g/dL.
Which precautions should a nurse include in the care plan for a client with leukemia and neutropenia?
Correct response: Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing. Explanation: Neutropenia occurs when the absolute neutrophil count falls below 1,000/mm3, reflecting a severe risk of infection. The nurse should provide a low-bacterial diet, which means eliminating fresh fruits and vegetables, avoiding invasive procedures such as enemas, and practicing frequent hand washing. Using a soft toothbrush, avoiding straight-edged razors and enemas, and monitoring for bleeding are precautions for clients with thrombocytopenia. Putting on a mask, gown, and gloves when entering the client's room are reverse isolation measures. A neutropenic client doesn't need a clear liquid diet or sodium restrictions.
A client with leukemia has developed a cough and increased fatigue. What is the primary nursing intervention?
Correct response: Evaluate the client for potential infection. Explanation: The client with leukemia has a lack of mature and normal granulocytes to fight infection. For this reason, the client is susceptible to infection. The primary nursing intervention is to evaluate for potential infection if the client has a cough and increased fatigue. Administering an antitussive would not be appropriate before determining the cause of the cough. A cooling blanket would not be needed if the client does not have a fever. Medicating the client to relieve pain would come after the assessment phase.
A nursing student is interested in working with children who have blood disorders. Which of the following terms would the student recognize as "the manufacture and development of blood cells."
Correct response: Hematopoiesis Explanation: Hematopoiesis is the manufacture and development of blood cells.
A client has been diagnosed with infectious mononucleosis. He asks the nurse how he contracted the illness. Which of the following would the nurse accurately identify as possible causes of the client's condition? Select all that apply.
Correct Response: Kissing Sharing cigarettes Being coughed or sneezed on Explanation: The Epstein-Barr virus causes infectious mononucleosis. This contagious disorder spreads by direct contact with saliva and pharyngeal secretions from an infected person. It is transmitted by kissing; oral spraying during coughing, talking, or sneezing; or sharing food, cigarettes, or other items containing oral secretions.
The client is receiving discharge teaching from the nurse regarding the oral monoclonal antibody erlotinib. What statement by the client indicates a need for additional teaching?
Correct response: "I will need to be sure and eat something with my meds." Explanation: For mAbs taken orally, there are no special precautions in handling, yet it is important to take them at the same time daily to support effectiveness. Food may exacerbate the skin rash of erlotinib if taken with a meal. All medications should be kept out of the reach of children. It is also important to not miss any doses if possible.
A client calls the clinic and informs the nurse of having a significant other diagnosed with infectious mononucleosis, wanting to know how long it will be before the client gets it. What does the nurse inform the client that the incubation period is for infectious mononucleosis?
Correct response: 30 to 50 days Explanation: The incubation period for infectious mononucleosis is 30 to 50 days. The other answers are incorrect.
A client reports feeling tired, cold, and short of breath at times. Assessment reveals tachycardia and reduced energy. What would the nurse expect the physician to order?
Correct response: CBC Explanation: Most clients with iron-deficiency anemia have reduced energy, feel cold all the time, and experience fatigue and dyspnea with minor physical exertion. The heart rate usually is rapid even at rest. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased. A CBC would be ordered.
A client recently diagnosed with a lymphatic disorder asks the nurse why the lymphatic system is so important. Which of the following would the nurse be correct in identifying as potential complications of a compromised lymphatic system? Select all that apply.
Correct response: Fluid distribution problems Tender, painful enlargement of lymph nodes Weakened immunity Explanation: Disorders of the lymphatic system result in fluid distribution problems, tender and painful lymph node enlargement, compromised immune function, or a combination of these.
A client diagnosed with acute myeloid leukemia has just been admitted to the oncology unit. When writing this client's care plan, which potential complication should the nurse address?
Correct response: Hemorrhage Explanation: Complications of AML include bleeding and infection, which are the major causes of death. The risk of bleeding correlates with the level and duration of platelet deficiency. The low platelet count can cause ecchymoses and petechiae. Major hemorrhages also may develop when the platelet count drops to less than 10,000/mm3. The most common bleeding sources include gastrointestinal (GI), pulmonary, vaginal, and intracranial. Pancreatitis, arteritis, and liver dysfunction are generally not complications of leukemia.
A client comes to the clinic and informs the nurse of swelling in right arm. There has been no injury or precipitating occurrence that caused the swelling. The nurse observes nonpitting edema from the upper arm to the fingertips. What action should the nurse initially perform?
Correct response: Inspect and measure the arm. Explanation: The nurse inspects and measures the affected area to assess the extent of enlargement and the condition of the skin initially. After collected the data, the nurse may instruct the client to elevate the arm and obtain the correct size for a compression stocking. Diuretic use is not an appropriate intervention at this time and would not be administered without a physician's order.
A client with lymphedema in the left arm has weeping from the skin and has a small 2-cm ulcer on the upper arm. What test does the nurse anticipate the client will be prepared for?
Correct response: Lymphangiography Explanation: Lymphangiography is a special examination in which an intravenous dye and radiography are used to detect lymph node involvement that reveals the degree and extend of blockage in the lymph system. An x-ray of the arm, ultrasound, or CT scan will not reveal the extent of blockage.
A client's absolute neutrophil count (ANC) is 440/mm3 but the nurse's assessment reveals no apparent signs or symptoms of infection. What action should the nurse prioritize when providing care for this client?
Correct response: Meticulous hand hygiene Explanation: Providing care for a client with neutropenia requires that the nurse adhere closely to standard precautions and infection control procedures. Hand hygiene is central to such efforts. Prophylactic antibiotics are rarely used and it is not possible to provide a sterile environment for care. Nutrition is highly beneficial, but hand hygiene is the central aspect of care.
A client is being treated in the hospital for hypovolemia related to a bleeding peptic ulcer. The nurse obtains a blood pressure reading of 88/62 mm Hg, heart rate of 112 beats/minute, and a respiratory rate of 24 breaths/minute. What is the first action by the nurse?
Correct response: Notify the physician. Explanation: A systolic blood pressure below 90 mm Hg and heart rate above 100 beats/minute should be reported immediately. Administering blood, inserting two large-bore IV catheters, and administration of a colloid solution should be performed only with a physician's order and may not be required at this time.
A nurse is caring for a client with iron deficiency anemia. Which food or beverage will the nurse suggest to the client to eat or drink when taking supplemental iron?
Correct response: Orange juice Explanation: Vitamin C found in orange juice improves the absorption of iron. The other answer choices are not the best for improving absorption of iron.
The nurse observes that a client who had an arterial blood gas performed 30 minutes ago is still oozing blood from the puncture site. Pressure was held to the site for 5 minutes after the puncture and another 5 minutes when the site was still oozing. What factor does the nurse know will participate in the ability for the blood to clot?
Correct response: Platelets Explanation: Platelets participate in clotting blood. Leukocytes protect against infection. Erythrocytes transport oxygen, and albumin affects intravascular osmotic pressure.
A young adult is preparing to begin treatment for non-Hodgkin lymphoma (NHL), a disease that has disseminated widely. What is the most likely treatment regimen for this patient that the nurse will help prepare?
Correct response: Radiation and chemotherapy Explanation: NHL is normally treated with either radiation (early stage) or radiation and chemotherapy (later stages). Antivirals, blood transfusion, surgery, bone marrow transplantation, and stem cell transplantations are not common treatment modalities for NHLs.
A client hospitalized with Hodgkin's disease is currently under visitor restrictions and asks the nurse why this is necessary. Which of the following explanations from the nurse is most accurate?
Correct response: Restricting visitors and personnel reduces the risk of transmission of pathogens to the client. Explanation: Reducing the number of organisms in the environment and restricting visitors and personnel with an infection reduce the transmission of pathogens to the client, whose immune system may be compromised as a result of the illness and treatment for it. While the client may be weak and does need rest, these are not the primary reasons for activity restrictions. The client's illness is not contagious.
You are caring for a patient with Hodgkin's lymphoma at the oncology clinic. While doing patient teaching you know you need to stress what?
Correct response: Risk of infection Explanation: Patients need to be taught to minimize the risks of infection, to recognize signs of possible infection, and to contact their health care provider if such signs develop. A nutritious diet and adequate sleep may be included in the teaching but will not be stressed like the risk of infection. Option D is a distracter for this question.
The client is receiving monoclonal antibody infusion. The client reports chills, hypertension, rash, and a metallic taste their mouth. The client suddenly experiences severe chest pain and goes into cardiac arrest. What does the nurse anticipate as the cause?
Correct response: Severe adverse reaction from the infusion Explanation: The client has experience adverse reactions to the infusion, specifically to the cardiovascular system. These reactions include chest pain, palpitations, hypo- or hypertension, tachy- or bradycardia, arrhythmia, edema, ischemia, infarction, and cardiac arrest. Many adverse reactions are mild and anticipated, but the nurse must be aware of the progression of adverse effects to the severe level during infusion. These reactions can happen to any client and are not necessarily linked to cardiac history, circulatory overload, or the possibility of embolus.
Laboratory and diagnostic test results have returned for a client with suspected lymphangitis. Which of the following would be most likely for the nurse to review in the results?
Correct response: Streptococcus Explanation: An infectious agent, commonly a streptococcal microorganism, usually causes both lymphangitis and lymphadenitis.
A nurse is having a discussion with a group of 14-year-old camp counselors about how infectious mononucleosis is transmitted. This disease is transmitted by:
Correct response: contact with the saliva of an infected person. Explanation: Infectious mononucleosis spreads by direct contact with saliva and pharyngeal secretions from an infected person. It is transmitted by kissing; oral spraying during coughing, talking, or sneezing; or sharing food, cigarettes, or other items containing oral secretions.
A nurse is caring for a client with acute myeloid leukemia who is preparing to undergo induction therapy. In preparing a plan of care for this client, the nurse should assign the highest priority to which nursing diagnosis?
Correct response: Risk for infection Explanation: Induction therapy places the client at risk for infection, thus this is the priority nursing diagnosis. During the time of induction therapy, the client is very ill, with bacterial, fungal, and occasional viral infections; bleeding and severe mucositis, which causes diarrhea; and marked decline in the ability to maintain adequate nutrition. Supportive care consists of administering blood products and promptly treating infections. Immobility, confusion, and spiritual distress are possible, but infection is the client's most acute physiologic threat.
A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?
Correct response: "I will receive parenteral vitamin B12 therapy for the rest of my life." Explanation: Because a client with pernicious anemia lacks intrinsic factor, oral vitamin B12 can't be absorbed. Therefore, parenteral vitamin B12 therapy is recommended and required for life.
A client had a left radical mastectomy with an axillary node dissection 6 months ago and is having a large amount of edema in the left arm down to the fingers. What should the nurse inform the client is the reason for the edema?
Correct response: An accumulation of lymphatic fluid that results from impaired lymph circulation. Explanation: Lymphedema is an accumulation of lymphatic fluid that results from impaired lymph circulation. It is a complication resulting from the removal of multiple lymph nodes at the time of mastectomy or radiation for cancer. It may be congenitally acquired, but in this situation, it is secondary and related to the mastectomy. Sodium intake would not be related to the accumulation of lymph fluid and would be generalized. There is not circulatory impairment from decreased blood flow but impaired lymphatic flow.
A client with lymphedema of the left leg has a nursing diagnosis of Altered Body Image Perception related to lymphedema of the left leg as evidenced by the statement, "I look terrible and am embarrassed to go out." What intervention can the nurse provide to help this client?
Correct response: Suggest certain styles of clothing that conceal the enlargement of the leg. Explanation: Extensive emotional support is necessary when the edema is severe. The client's self-esteem often is decreased, which can lead to social withdrawal. The nurse supports the client's self-image by suggesting certain styles of clothing that conceal abnormal enlargement of an arm or leg. Informing the client to stay away from social activities can create a depressed mood and loneliness. The client should not be encouraged to go out and socialize if he is not ready nor referred to a psychiatrist at this point.
Which statement best describes the function of stem cells in the bone marrow?
Correct response: They produce all blood cells. Explanation: All blood cells are produced from undifferentiated precursors called pluripotent stem cells in the bone marrow. Other cells produced from the pluripotent stem cells help defend against bacterial infection, produce antibodies against foreign antigens, and are active against hypersensitivity reactions.
The most common cause of iron deficiency anemia in men and postmenopausal women is
Correct response: bleeding. Explanation: The most common cause of iron deficiency anemia in men and postmenopausal women is bleeding from ulcers, gastritis, inflammatory bowel disease or gastrointestinal (GI) tumors. Menorrhagia is the most common cause in premenopausal women. Iron malabsorption is another cause, which is seen in clients with celiac disease. Clients with chronic alcoholism often have chronic blood loss from the GI tract.
An adult client has been diagnosed with iron-deficiency anemia. What nursing diagnosis is most likely to apply to this client's health status?
Correct response: Fatigue related to decreased oxygen-carrying capacity Explanation: Fatigue is the major assessment finding common to all forms of anemia. Anemia does not normally result in acute pain or fluid deficit. The client may have an increased risk of infection due to impaired immune function, but fatigue is more likely.
The nurse is assisting the client with multiple myeloma to ambulate. What is the most important nursing intervention to help prevent fractures in the client?
Correct response: Promote safety. Explanation: Safety is paramount because any injury, no matter how slight, can result in a fracture. Mobility, hydration, and nutrition are important, but will not prevent fractures.
An adult client reports that it is taking longer than usual for minor cuts and injuries to clot. Which of the following questions would the nurse most likely ask the client?
Correct response: "Are you regularly taking aspirin?" Explanation: Aspirin and anticoagulants can contribute to bleeding and interfere with clot formation. Sugary foods, allergy, and asthma would not influence the client's clotting capacity. Hemophilia is a disorder of clotting, but it manifests from early in childhood as a genetic problem and would not suddenly appear in adulthood.
A client with leukemia is scheduled to begin treatment with a cytokine. What anticipatory guidance should the nurse provide?
Correct response: "You'll likely feel flu-like after starting this medication." Explanation: Cytokines often cause flu-like symptoms. Treatment involves multiple doses but a temporary worsening of symptoms is not expected. Mental confusion is not noted to be a common adverse effect.
The client was admitted to the Emergency Department after an accident with a chain saw. The client is exhibiting signs and symptoms of acute hypovolemic anemia from severe blood loss. What signs and symptoms would the nurse assess for?
Correct response: Reduced urine output Explanation: Acute hypovolemic anemia from severe blood loss is evidenced by the signs and symptoms of hypovolemic shock, which include reduced urine output. The symptoms of chronic hypovolemic anemia include fatigue and postural hypotension. Clients with malabsorption disorders are at great risk of iron deficiency anemia.
The client has a family history of colon cancer. The client asks the nurse about getting the vaccine like a family member had received. What should the nurse say to the client?
Correct response: "Cancer vaccines are individualized to treat one person's cancer." Explanation: Cancer vaccines are used in treatment of cancer, made from the client's own tumor cells, and thus are individualized. They are not preventative vaccines. There is only one cancer vaccine currently on the market, sipuleucel-T, which is used in the treatment of prostate cancer, but many are in the research and development stages. It is the hope that vaccines will be able to eradicate all types of cancer, but at this time this is not a true statement.
A client with megaloblastic anemia reports mouth and tongue soreness. What instruction will the nurse give the client regarding eating while managing the client's symptoms?
Correct response: "Eat small amounts of bland, soft foods frequently." Explanation: Because the client with megaloblastic anemia often reports mouth and tongue soreness, the nurse should instruct the client to eat small amounts of bland, soft foods frequently. The other answer choices do not factor in the client's mouth soreness or need for nutrition.
The nurse is teaching the client about immune drug therapy before treatment begins in the home. What statement by the client indicates a need for further instruction?
Correct response: "I won't contact my doctor unless I have blood in my stool." Explanation: The client needs further instruction regarding when to contact the provider. Diarrhea is a common GI adverse effect and colitis can develop. Waiting until blood is seen indicates that the client needs further education since even minor adverse reactions should be reported immediately so that intervention can be made. The client and family should be taught the generic and brand or trade names of these medications to avoid confusion. The client should take the drug only as directed on the prescription container and never increase, decrease, or omit a dose unless advised to do so by the provider. The client should set reminders such as on a calendar, cellphone alarm, or computer alert so that meds can be taken on schedule.
A client has an increased number of eosinophils. Which of the following disorders would the nurse expect the client to have?
Correct response: Allergy Explanation: Eosinophils phagocytize foreign material. Their numbers increase in allergies, some dermatologic disorders, and parasitic infections.
A group of nurses are learning about the high incidence and prevalence of anemia among different populations. Which individual is most likely to have anemia?
Correct response: An 81-year-old woman who has chronic heart failure Explanation: The incidence and prevalence of anemia are exceptionally high among older adults, and the risk of anemia is compounded by the presence of heart disease. None of the other listed individuals exhibits high-risk factors for anemia, though exceptionally heavy menstrual flow can result in anemia.
Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process in a client with leukemia?
Correct response: Apply prolonged pressure to needle sites or other sources of external bleeding. Explanation: For a client with leukemia, the nurse should apply prolonged pressure to needle sites or other sources of external bleeding. Reduced platelet production results in a delayed clotting process and increases the potential for hemorrhage. Implementing neutropenic precautions and eliminating direct contact with others are interventions to address the risk for infection.
After receiving a diagnosis of acute lymphocytic leukemia, a client is visibly distraught, stating, "I have no idea where to go from here." How should the nurse prepare to meet this client's psychosocial needs?
Correct response: Assess the client's specific needs for education and support. Explanation: In order to meet the client's needs, the nurse must first identify the specific nature of these needs. According to the nursing process, assessment must precede interventions. The plan of medical care is important, but not central to the provision of support. The client's previous health care is not a primary consideration, and the nurse cannot assure the client of successful treatment.
A nurse is providing discharge education to a client who has recently been diagnosed with a bleeding disorder. Which topic should the nurse prioritize when teaching this client?
Correct response: Avoiding activities that carry a risk for injury Explanation: Clients with bleeding disorders need to understand the importance of avoiding activities that increase the risk of bleeding, such as contact sports. Immunizations involve injections and may be contraindicated for some clients. Clients with bleeding disorders do not need to normally avoid crowds. Foods high in vitamin K may be beneficial, not detrimental.
The nurse is providing care for a patient with a diagnosis of cellulitis. What laboratory value would the nurse assess most closely to gauge the patient's infection?
Correct response: White blood cell (WBC) count Explanation: To monitor infection, the nurse should closely monitor the patient's WBC count.
The client is taking erlotinib as part of cancer treatment. Which client concern will the nurse assess as an indication that the medication is working?
Correct response: Acne-like rash during therapy Explanation: With checkpoint inhibitors such as erlotinib or gefitinib, not all reactions indicate a problem. Clients on erlotinib, as stated in the question, or gefitinib have better outcomes when the client develops an acne-like rash during therapy. Clients that are treated with the medication bevacizumab who have an increase in blood presssure also tend to have better outcomes but only for the medication bevacizumab not erlotinib. The presence of diarrhea is an adverse effect in the GI system of these medications but does not signal a better outcome. Photosensitivity is a integumenary system reaction but does not signal a better outcome.
The nurse observes a co-worker who always seems to be eating a cup of ice. The nurse encourages the co-worker to have an examination and diagnostic workup with the health care provider. What type of anemia is the nurse concerned the co-worker may have?
Correct response: Iron deficiency anemia Explanation: People with iron deficiency anemia may crave ice, starch, or dirt; this craving is known as pica.
A 18-year-old client presents to the emergency department with a severe open fracture of the lower extremity. The health care provider tells the client that the client will need a blood transfusion. The client refuses, despite the advise of the health care provider. What does the nurse understand is the legal implication of the scenario?
Correct response: The client has a right to refuse the transfusion. Explanation: An 18-year-old client may refuse transfusion if the client is of sound mind and has been provided education on the risks and benefits of the transfusion. An 18-year-old client is considered an adult and does not require the consent of his or her parent.
A client is recovering from infectious mononucleosis and asks the nurse when he or she will finally be rid of the disease. How should the nurse most accurately respond?
Correct response: "You are now immune to mono, but the virus will remain in your body for the rest of your life." Explanation: The symptoms resolve in approximately 1 to 2 weeks unless complications develop. One episode of infectious mononucleosis produces subsequent immunity; however, the virus remains in the body for the person's lifetime.
A client is being treated for anemia and has a hemoglobin level of 9.6 g/dL. What does the nurse understand is the basic nutritional component of heme in hemoglobin that the client may be deficient in?
Correct response: Iron Explanation: Iron is the basic nutritional component of heme in hemoglobin. Folic acid is essential for the maturation of red blood cells. Copper (minute amount) is involved in the transfer of iron from storage to plasma.
A client is in the early stages of Hodgkin's disease. When palpating the client's lymph nodes, the nurse is most likely to find that the lymph nodes are:
Correct response: enlarged and painless. Explanation: Early symptoms of Hodgkin's disease include painless enlargement of one or more lymph nodes.
A client who has Hodgkin's disease should have their bed in high-Fowler's position whenever practical to:
Correct response: increase lung expansion. Explanation: Those who have Hodgkin's disease are at risk for ineffective airway clearance and impaired gas exchange. High-Fowler's position promotes lung expansion.
The nurse is providing education to a patient with iron deficiency anemia who has been prescribed iron supplements. What statement should the nurse include in patient education?
Correct response: "Iron will likely cause your stools to darken in color." Explanation: The nurse will inform the patient that iron will cause the stools to become dark in color. Iron should be taken on an empty stomach, as its absorption is affected by food, especially dairy products. Patients should be instructed to increase their intake of vitamin C to enhance iron absorption. Foods high in fiber should be consumed to minimize problems with constipation, a common side effect associated with iron therapy.
The nurse is assigned to care for a client with polycythemia vera. When the nurse encourages the client to drink 3 L of fluid per day, the client states, "Why do I have to drink so much?" What is the best response by the nurse?
Correct response: "It helps adequately hydrate you and ensures a sufficient urine production." Explanation: The client should be advised to drink 3 quarts (or liters) per day. Adequate hydration promotes venous return and ensures sufficient urine production. Informing the client that the healthcare team does not want them to get dehydrated does not address the rationale that the client requires. Fluid hydration will not help the heart beat regularly or more effectively and it will not help to restrict blood circulation.
A client with acute kidney injury has decreased erythropoietin production. Upon analysis of the client's complete blood count, the nurse will expect which of the following results?
Correct response: A decreased hemoglobin and hematocrit Explanation: The decreased production of erythropoietin will result in a decreased hemoglobin and hematocrit. The client will have normal MCV and RDW because the erythrocytes are normal in appearance.
A night nurse is reviewing the next day's medication administration record (MAR) of a hospital client who has hemophilia. The nurse notes that the MAR specifies both oral and subcutaneous options for the administration of a PRN antiemetic. What is the nurse's best action?
Correct response: Contact the prescriber to have the subcutaneous option discontinued. Explanation: Injections must be avoided in clients with hemophilia. Consequently, the nurse should ensure that the prescriber makes the necessary change. The nurse cannot independently make a change to a client's MAR in most cases. Facilitating the necessary change is preferable to deferring to the day nurse.
A nurse on a hematology/oncology floor is caring for a client with aplastic anemia. Which would not be included in the client's discharge instructions?
Correct response: Use a disposable razor when shaving. Explanation: People with aplastic anemia usually have insufficient erythrocytes, leukocytes, and platelets. Encourage behaviors that will lower the risk for bleeding. Avoiding contact with people who are sick reduces the risk of acquiring an infection. Handwashing reduces the risk of acquiring an infection. Anemia can cause fatigue and shortness of breath with even mild exertion.
The nurse is caring for the client with infectious mononucleosis that has inflammation of the pharyngeal mucosa. What foods or liquids would be best to offer to this client?
Correct response: Vanilla pudding and iced tea Explanation: Vanilla pudding and iced tea would be appropriate food for the nurse to offer. Soft, bland foods; cool liquids; and gargling with warm salt water are best for clients with inflammation of the oral and pharyngeal mucosa. Hot milk, tomato soup, hot tea, and beef and broccoli stir fry would not help with the inflammation of the pharynx.
A nurse is caring for a client who developed toxicity after long-term treatment with sulfasalazine for Crohn's disease. The client is experiencing fatigue, fever, chills, and headache and is at risk to develop opportunistic infections. Which condition has the client most likely developed?
Correct response: agranulocytosis Explanation: Agranulocytosis refers specifically to a decreased production of granulocytes, neutrophils, basophils, and eosinophils. The most common cause of agranulocytosis is toxicity from drugs such as sulfonamides, chloramphenicol (Chloromycetin), antineoplastic, and some psychotropic medications. Clients with leukopenia have a general reduction in all WBCs. Clients with hemolytic anemia have a chronic premature destruction of erythrocytes. Pernicious anemia develops when a client lacks intrinsic factor, which normally is present in stomach secretions.
A teenage client presents with severe fatigue, sore throat, headache, oozing tonsils, and cervical lymph node enlargement. Which accessory lymphatic structure could enlarge?
Correct response: spleen Explanation: The tonsils, thymus gland, and spleen are accessory lymphatic structures. Infectious mononucleosis results in the production of B-cell lymphocytes and antibodies that infiltrate tissue, particularly the spleen, causing it to enlarge.
A client with lymphedema is struggling with negative emotions related to her appearance. Which of the following suggestions from the nurse would be most effective in helping the client address the problem?
Correct response: "Let's discuss some clothing styles that can help conceal the problem while you are being treated." Explanation: Extensive emotional support is necessary when the edema is severe. The client's self-esteem often is decreased, which can lead to social withdrawal. The nurse supports the client's self-image by suggesting certain styles of clothing that conceal abnormal enlargement of an arm or leg. Telling the client not to dwell on the problem is dismissive and inappropriate; also, sometimes lymphedema does not go away. The nurse should not automatically suggest spiritual counseling to assist with a client's practical problem, unless a client specifically initiates interest in such a referral. While it might be helpful for the client to spend the most time with the people with whom she feels most comfortable, this may increase her isolation. It also may not be practical if a client must return to work or other activities.
An adolescent client diagnosed with infectious mononucleosis asks the nurse if it is possible to keep from getting the disease in the future. What is the best response by the nurse?
Correct response: "One episode produces immunity, but the virus remains for a lifetime." Explanation: One episode of infectious mononucleosis produces subsequent immunity; however, the virus remains in the body for the person's lifetime. The virus does not dissipate and go away. If a client has an incidence of infection, the client is immune from further infections of Epstein-Barr virus. The symptoms do not generally go away for 2 to 6 weeks.
A nurse is explaining the processes related to hemoglobin to a client with a clotting disorder. Place the steps in the correct order from first to last that the nurse would outline.
Correct response: Erythrocytes pass through the lungs. Hemoglobin picks up oxygen and releases CO2. Oxygenated, bright red blood is carried by arteries, arterioles, and capillaries to all body tissues. Hemoglobin releases oxygen for use by the tissues. Dark red blood returns by way of the veins to the heart and lungs. CO2 is released and the blood is reoxygenated. Explanation: As erythrocytes pass through the lungs, the hemoglobin picks up oxygen and releases CO2. Oxygenated blood is bright red and carried by arteries, arterioles, and capillaries to all body tissues. After hemoglobin releases oxygen for use by the tissues, the hemoglobin is called reduced (or deoxygenated) hemoglobin. The blood becomes dark red and returns by way of the veins to the heart and lungs, where CO2 is released and the blood is reoxygenated.
The LPN is following a plan of care for a client who is being treated for hypovolemic anemia and is at risk for hypovolemic shock. The nurse assesses vital signs and O2 saturation and observes the saturation at 89% for 3 minutes. What should the first action by the nurse be?
Correct response: Give oxygen per nasal cannula Explanation: An expected outcome for the client with hypovolemic anemia is to monitor to detect hypoxemia and manage and minimize inadequate oxygenation. The oxygen saturation should be monitored to measure the percentage of oxygen bound to hemoglobin. The nurse should report a sustained oxygen saturation value below 90%. Give oxygen per nasal cannula or simple mask to maintain oxygen saturation at or above 90%. It is important to administer the oxygen first and then contact the charge nurse to alert them. It is not necessary at this time if the client is not in respiratory distress to intubate the client. Placing the client in the supine position would decrease the oxygen saturation level further.
The nurse recognizes the clinical assessment of a patient with acute myeloid leukemia (AML) includes observing for signs of infection early. What nursing action will most likely help prevent infection?
Correct response: Practice vigilant handwashing. Explanation: Infection prevention is best handled by vigilant handwashing. Monitoring the client's temperature once a shift is not often enough. The client will take precautions, but precautions are enough to prevent infections. Encouraging increased fluid consumption will not prevent infection.
The nurse is obtaining objective data from a client with lymphangitis of the left arm. What does the nurse expect to find when collecting this data from the client?
Correct response: Red streaks following the course of the lymph channels Explanation: Red streaks follow the course of the lymph channels and extend up the arm or leg. Fever also may be present. When lymphadenitis is present, the lymph nodes along the lymphatic channels are enlarged and tender on palpation. Diagnosis is made by visual inspection and palpation. The nurse does not expect to find a pulsatile mass. Weeping and oozing would indicate lymphedema. The arm would be warm or hot, not cold and clammy.
Parents arrive to the clinic with their young child and inform the nurse the child has just been diagnosed with sickle cell disease. The parents ask the nurse how this could have happened and which one of them is the carrier. What is the best response by the nurse?
Correct response: "The child must inherit two defective genes, one from each parent." Explanation: Sickle cell disease is a hereditary disorder. To manifest this disorder, a person must inherit two defective genes, one from each parent, in which case all the hemoglobin is inherently abnormal. If the person inherits only one gene, the person carries the sickle cell trait. The hemoglobin of those who have sickle cell trait is about 40% affected. The other distractors are incorrect due to these factors.
The healthcare provider has informed the client about the client's need to have immunotherapy treatments. The client asks the nurse, "Will I need to be in the hospital for these treatments?" What should be the nurse's response?
Correct response: "The treatment environment depends on the extent of the disease and the complexity of the treatment." Explanation: A client may be treated as an outpatient in the ambulatory setting or as an inpatient in a hospital. Administration environment is dependent upon the extent of disease, comorbidity, or the complexity of this or other therapies. Clients have a right to choose treatment options; a new center does not necessarily mean that is where the client may want to go.
The nurse is caring for a group of clients. Which client does the nurse suspect is most likely to have mononucleosis?
Correct response: A 19-year-old college student with cervical node enlargement and fever Explanation: The virus most commonly affects young adults, especially those in close living quarters, such as armed services housing and college dormitories. Fatigue, fever, sore throat, headache, and cervical lymph node enlargement typically occur. The tonsils ooze white or greenish-gray exudates. Pharyngeal swelling can compromise swallowing and breathing. Some clients develop a faint red rash on their hands or abdomen. The liver and spleen become enlarged. The other clients with presenting symptoms do not correlate with the symptoms of mononucleosis.
A client with sickle cell crisis is admitted to the hospital in severe pain. While caring for the client during the crisis, which is the priority nursing intervention?
Correct response: Administering and evaluating the effectiveness of opioid analgesics Explanation: The priority nursing intervention is to manage the acute pain. Client-controlled analgesia is frequently used in the acute care setting. A patient with sickle cell crisis experiences severe extreme pain, the use of IV fluids and oral intake is need to hydrate the patient, the patient is initially placed on bed rest during the crisis due to extreme fatigue. The patient must continue to ingest folic acid and are placed on a daily folic acid supplement .
The clinical nurse educator is presenting health promotion education to a client who will be treated for non-Hodgkin lymphoma on an outpatient basis. The nurse should recommend which of the following actions?
Correct response: Avoiding highly crowded public places Explanation: The risk of infection is significant for these clients, not only from treatment-related myelosuppression but also from the defective immune response that results from the disease itself. Limiting infection exposure is thus necessary. The need to avoid grapefruit is dependent on the client's medication regimen. Sun exposure and the use of razors are not necessarily contraindicated.
When teaching a client with iron deficiency anemia about appropriate food choices, the nurse encourages the client to increase the dietary intake of which foods?
Correct response: Beans, dried fruits, and leafy, green vegetables Explanation: Food sources high in iron include organ meats (e.g., beef or calf liver, chicken liver), other meats, beans (e.g., black, pinto, and garbanzo), leafy and green vegetables, raisins, and molasses. Taking iron-rich foods with a source of vitamin C (e.g., orange juice) enhances the absorption of iron.
A woman who is in her third trimester of pregnancy has been experiencing an exacerbation of iron-deficiency anemia in recent weeks. When providing the client with nutritional guidelines and meal suggestions, what foods would be most likely to increase the woman's iron stores?
Correct response: Beef liver accompanied by orange juice Explanation: Food sources high in iron include organ meats, other meats, beans (e.g., black and pinto), leafy green vegetables, raisins, and molasses. Taking iron-rich foods with a source of vitamin C (e.g., orange juice) enhances the absorption of iron. All of the listed foods are nutritious, but liver and orange juice are most likely to be of benefit to iron stores.
A nurse is documenting skin findings in a client with lymphedema. Which of the following descriptions would be most consistent with the expected presentation?
Correct response: Brawny Explanation: The skin of the client with lymphedema can appear thickened, rough, and discolored; it is described as brawny (orange). Rubor means a red appearance; cyanotic is a bluish skin tone when oxygenation to tissues is impaired; and jaundice is a yellow skin tone that develops in client with liver problems.
A nurse is caring for a client with a low platelet count. The nurse understands that a low platelet count affects which of the following?
Correct response: Clotting of blood Explanation: The nurse understands that a low platelet count affects clotting of blood. T lymphocytes or T cells are responsible for immune response. Eosinophils are involved in the detoxification of foreign particles. Basophils are involved in the release of histamines.
The client has been ordered a checkpoint inhibitor for cancer. Upon reviewing the client's health history and medication list, which medication will the nurse need to inform the healthcare provider about?
Correct response: Clozapine Explanation: The medication clozapine is commonly used to manage psychiatric problems, but when given with a checkpoint inhibitor as referenced in the scenario, which is a subclass of mAbs, there is increased risk for central nervous system (CNS) toxicity. The medication roflumilast is used in the treatment of respiratory problems and should not be given together with monoclonal antibody (mAb) due to increased risk for immunosuppression. The CNS toxicity would be the most concerning with the clozapine. The medication cladribine is used in chemotherpay and should not be given with cytokines due to increased lymphopenia, not checkpoint inhibitors, and adverse interferon reactions and the medication zidovudine are used to treat HIV and is an antiretroviral, when given with cytokines not checkpoint inhibitors, there is increased adverse reactions of the zidovudine.
A client newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment, the client asks the nurse to explain the condition. The nurse explains to this client that this condition occurs due to which factor?
Correct response: Decreased production of platelets Explanation: Thrombocytopenia can result from a decreased platelet production, increased platelet destruction, or increased consumption of platelets. Impaired platelet communication, antibodies, and autoimmune processes are not typical pathologies.
A 66-year-old man underwent a successful partial gastrectomy for the treatment of stomach cancer 3 years ago. The man had a scheduled follow-up appointment with his primary caregiver and had blood work completed. The results of the man's blood work indicated anemia. The nurse who is contributing to the patient's care should recognize that this patient's anemia may be attributable to what factor?
Correct response: Decreased vitamin B12 absorption Explanation: It is important for nurses to recall that patients who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and therefore the absorption of vitamin B12 may be diminished, leading to anemia. Paralytic ileus would not be plausible; infection and cancer would be less likely causes for the patient's iron deficiency.
The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions?
Correct response: Dilute the liquid preparation with another liquid such as juice and drink with a straw. Explanation: Dilute liquid preparations of iron with another liquid such as juice and drink with a straw to avoid staining the teeth. Avoid taking iron simultaneously with an antacid, which interferes with iron absorption. Drink orange juice or take other forms of vitamin C with iron to promote its absorption. Expect iron to color stool dark green or black.
The nurse is caring for a client in the hospital who is being treated for Hodgkin's disease and is taking a chemotherapeutic regimen in the hospital's oncology unit. When reviewing the client's medication history, what regimen does the nurse recognize as the drugs in the treatment of Hodgkin's disease?
Correct response: Doxorubicin, bleomycin, vinblastine, dacarbarine Explanation: Doxorubicin, bleomycin, vinblastine, and dacarbarine are a combination of medications for the chemotherapeutic treatment of Hodgkin's disease. There are several different regimens that may be used but the medications in the other options are not used for the treatment of Hodgkin's disease.
A thin client is prescribed iron dextran intramuscularly. What is most important action taken by the nurse when administering this medication?
Correct response: Employs the Z-track technique Explanation: When iron medications are given intramuscularly, the nurse uses the Z-track technique to avoid local pain and staining of the skin. The gluteus maximus muscle is used. The nurse avoids rubbing the site vigorously and uses a 18- or 20-gauge needle.
A physician has arrived on the floor to perform a bone marrow aspiration. The nurse first
Correct response: Ensures that the client has signed the informed consent form Explanation: A signed informed consent is needed before a bone marrow aspiration is performed. The nurse may then obtain a bone marrow aspiration tray, administer an anti-anxiety medication to the client, and position the client on the left side for the procedure.
A client undergoing a complete blood cell (CBC) count for the detection of anemia wants to know more about hemoglobin. Which should the nurse explain to the client as being the main function of hemoglobin?
Correct response: Gives its oxygen to cells of the body and picks up carbon dioxide Explanation: The iron in hemoglobin picks up oxygen in a loose chemical combination. As blood circulates through the capillaries, the hemoglobin gives its oxygen to various cells of the body and picks up their carbon dioxide. Defending the body against disease organisms, toxins, and irritants, being essential for blood clotting, plug formation, and further hemostasis, or releasing chemicals to assist the body in detoxifying foreign proteins, are not the main functions of hemoglobin. WBCs defend the body against disease organisms, toxins, and irritants. Platelets are essential for blood clotting, plug formation, and hemostasis. Eosinophils release chemicals to assist the body in detoxifying foreign proteins.
The client on immunotherapy is experiencing loose stools. Which meal would the nurse recommend as being best for this client?
Correct response: Grilled chicken with steamed vegetables and water Explanation: The best meal or this client would be the grilled chicken, steamed vegetables, and water. Diarrhea may be a GI adverse reaction to immunotherapy. Instruct the client to avoid foods like caffeine, alcohol, and high roughage. Encourage foods with bulk such as apples, oatmeal, bananas, white rice, and cooked vegetables. Be sure the client drinks fluid to replace the loss from diarrhea. The meal with the chef salad and kale may be very high in roughage, and tea has caffiene which will make diarrhea worse. The fried fish meal with potato salad may be irritating due to the frying of the fish or battering the fish before frying. The sausage/cabbage meal with coffee would be avoided due to the caffeine in the coffee and cabbage may cause abdominal discomfort due to flatus.
A client with lymphadenitis has developed persistent swelling of the affected area. What would be important information for the nurse to teach this client?
Correct response: How to apply an elastic sleeve or stocking Explanation: The nurse inspects the area two to three times daily and notes the client's response to antibiotic therapy. He or she gives assistance if the discomfort interferes with activities of daily living. Elevation reduces the swelling. Warmth promotes comfort and enhances circulation. The nurse notifies the physician if the affected area appears to enlarge, additional lymph nodes become involved, or body temperature remains elevated. In severe cases with persistent swelling, the nurse teaches the client how to apply an elastic sleeve or stocking. Ice does not reduce the swelling. Exercise does not reduce the swelling.
A nurse in a long-term care facility is admitting a new resident who has a bleeding disorder. When planning this resident's care, the nurse should include which action?
Correct response: Implementing of a plan for fall prevention Explanation: To prevent bleeding episodes, the nurse should ensure that an older adult with a bleeding disorder does not suffer a fall. Activity limitation is not necessarily required, however. A private room is not necessary and there is no reason to increase fiber intake.
The nurse is caring for a patient with a hematologic disorder. The patient asks the nurse where the body forms blood cells. Where should the nurse tell the patient that blood cells are formed?
Correct response: In the bone marrow Explanation: Bone marrow is the primary site for hematopoiesis. The liver and spleen may be involved during embryonic development or when marrow is destroyed. The kidneys release erythropoietin, which stimulates the marrow to increase production of RBCs. Blood cells are not formed in the spleen, the kidneys, or the liver.
A nurse is planning the care of a client with a diagnosis of sickle cell disease who has been admitted for the treatment of an acute vaso-occlusive crisis. Which nursing diagnosis should the nurse prioritize in the client's plan of care?
Correct response: Ineffective tissue perfusion related to thrombosis Explanation: There are multiple potential complications of sickle cell disease and sickle cell crises. Central among these, however, is the risk of thrombosis and consequent lack of tissue perfusion. Sickle cell crises are not normally accompanied by impaired thermoregulation or genitourinary complications. Risk for disuse syndrome is not associated with the effects of acute vaso-occlusive crisis.
A nurse is caring for a client who has a diagnosis of acute myelocytic leukemia (AML). Assessment of which factor most directly addresses the most common cause of death among clients with leukemia?
Correct response: Infection status Explanation: Because of the lack of mature and normal granulocytes that help fight infection, clients with leukemia are prone to infection. In clients with AML, death typically occurs from infection or bleeding. Symptoms of AML include weight loss, fever, night sweats, and fatigue, which would guide the nurse to monitor the client's nutrition and electrolytes. Gastrointestinal problems (nausea and vomiting) and electrolyte imbalances (hyperkalemia and hypocalcemia) may result from chemotherapy use. The liver is responsible for metabolism and metabolic detoxification, so monitoring liver function is important for the client who is receiving chemotherapy. These problems may contribute to and/or result in death but are not the most common cause.
A patient has come to the Ob-Gyn clinic with complaints of a heavy menstrual flow. The nurse knows that red blood cell production will be increased in the patient's body. Because of this, the nurse is aware that the patient may need to increase her daily intake of what?
Correct response: Iron Explanation: To replace blood loss, the rate of red cell production increases. Iron is incorporated into hemoglobin. Vitamins C and D and magnesium do not need to be increased when red blood cell production is increased.
A nursing instructor is evaluating a student caring for a neutropenic client. The instructor concludes that the nursing student demonstrates accurate knowledge of neutropenia based on which intervention?
Correct response: Monitoring the client's temperature and reviewing the client's complete blood count (CBC) with differential Explanation: Clients with neutropenia often do not exhibit classic signs of infection. Fever is the most common indicator of infection, yet it is not always present. No definite symptoms of neutropenia appear until the client develops an infection. A routine CBC with differential can reveal neutropenia before the onset of infection.
The nurse is caring for a client with lymphangitis of the right leg who is receiving treatment with a broad-spectrum antibiotic. The nurse is giving a bath and observes the right leg is larger than it was 2 hours ago and the client feels hot. What is the first action by the nurse?
Correct response: Notify the physician. Explanation: The nurse notifies the physician if the affected area appears to enlarge, additional lymph nodes become involved, or body temperature remains elevated. In severe cases with persistent swelling, the nurse teaches the client how to apply an elastic sleeve or stocking. The leg should be elevated to reduce the edema. A warm compress may be applied to promote comfort and enhance circulation. Passive range of motion would be contraindicated at this time.
A 16-year-old girl has been brought to her primary care provider by her mother due to the daughter's recent malaise and lethargy. Which of the following assessments should the clinician perform in an effort to confirm or rule out infectious mononucleo
Correct response: Palpating the patient's lymph nodes Explanation: In cases of infectious mononucleosis, the lymph nodes are typically enlarged throughout the body, particularly in the cervical, axillary, and groin areas. Palpation of these nodes is a priority assessment in cases of suspected mononucleosis. Bone pain, adventitious lungs sounds, and abnormal cranial nerve reflexes do not accompany mononucleosis.
A client with non-Hodgkin's lymphoma is receiving chemotherapy for treatment. The client is complaining of nausea during treatment. To maintain fluid intake, what type of food or fluid could the nurse offer the client?
Correct response: Popsicle Explanation: Offer clear liquids such as carbonated beverages and water, ice pops, and flavored gelatin until nausea subsides. Thereafter, small, frequent, low-fat meals help prevent nausea, improve nutritional intake, and reduce weight loss. Milk, pudding, and chicken are too heavy when clients are experiencing nausea and may be given after the nausea subsides.
A client is having a lymph node biopsy for suspicion of Hodgkin's disease. What type of cells would be identifiable in the lymph node biopsy that may indicate this disease process?
Correct response: Reed-Sternberg cells Explanation: The Reed-Sternberg cells, characterized as giant multinucleated B lymphocytes, are microscopically identifiable in lymph node biopsies. Sickled red blood cells would indicate sickle cell disease but would be identifiable in a blood test, not a lymph node biopsy. The Epstein-Barr virus is linked to the development of Hodgkin's disease, but the virus is not identified in the lymph node biopsy. Red blood cells would be seen normally on blood tests.
A client is prescribed 325 mg/day of oral ferrous sulfate. What does the nurse include in client teaching?
Correct response: Take 1 hour before breakfast Explanation: Instructions the nurse will provide for the client taking oral ferrous sulfate is to administer the medication on an empty stomach. Instructions also include that there is decreased absorption of iron with food, particularly dairy products. The client is to increase vitamin C intake (fruits, juices, tomatoes, broccoli), which will enhance iron absorption. The client is to also increase foods high in fiber to decrease risk of constipation.
A 60-year-old client with chronic myeloid leukemia (CML) will be treated in the home setting, and the nurse is preparing appropriate health education. Which topic should the nurse emphasize?
Correct response: The importance of adhering to the prescribed drug regimen Explanation: Nurses need to understand that the effectiveness of the drugs used to treat CML is based on the ability of the client to adhere to the medication regimen as prescribed. Adherence is often incomplete, thus this must be a focus of health education. Vaccinations normally would not be given during treatment and daily physical activity may be impossible for the client. Dietary restrictions are not normally necessary.
A client is treated for anemia. What is the nurse's best understanding about the correlation between anemia and the client's iron stores?
Correct response: There is a strong correlation between iron stores and hemoglobin levels. Explanation: A strong correlation exists between laboratory values that measure iron stores and hemoglobin levels. After iron stores are depleted (as reflected by low serum ferritin levels), the hemoglobin level falls.
A female client has been diagnosed with cancer and will begin treatment using monoclonal antibodies. What should the nurse teach the client about this new drug regimen?
Correct response: There will be fewer adverse reactions than with chemotherapy. Explanation: In general, mAbs carry fewer adverse effects than chemotherapy. They are not necessarily contraindicated during radiation therapy. Due to possible teratogenic effects, mAbs are contraindicated during pregnancy. Because of their immunosuppressive effect, they increase rather than decrease the risk for infection.
After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/mm3. What term should the nurse use to describe this low platelet count?
Correct response: Thrombocytopenia Explanation: A normal platelet count is 140,000 to 400,000/mm3 in adults. Chemotherapeutic agents produce bone marrow depression, resulting in reduced red blood cell counts (anemia), reduced white blood cell counts (leukopenia), and reduced platelet counts (thrombocytopenia). Neutropenia is the presence of an abnormally reduced number of neutrophils in the blood and is caused by bone marrow depression induced by chemotherapeutic agents.
