Immune and Hematologic Passpoint

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

Ineffective tissue perfusion: cerebral, cardiopulmonary, GI

A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement made by the client about safer sex practices for persons with HIV is accurate?

"A latex condom provides the best protection against HIV transmission during sexual intercourse."

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

"I should drink plenty of fluids when taking allopurinol."

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

"I take them to the pool where it is possible to exercise with other children."

A client in sickle cell crisis has been hospitalized during pregnancy. After giving discharge instructions, the nurse determines the client needs further teaching when they make which statement?

"I will need to take an iron supplement even if my laboratory values are normal."

A staff member on the transplant unit is having problems logging into the computer to chart client information. The staff member asks a nurse for their personal identification number (PIN) to log in. What is the nurse's best response?

"I'll be happy to contact Information Services to assist you with the problem."

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

"I'll dilute the medication and drink it with a straw."

The nurse is caring for a client who has been diagnosed with pernicious anemia. Which statement by the client indicates an understanding of the treatment of pernicious anemia?

"I'll need to take vitamin B12 replacements for the rest of my life."

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

"Take a warm tub bath or shower before exercising. This may help with your discomfort."

A client with rheumatoid arthritis reports gastrointestinal irritation after taking piroxicam. To prevent gastrointestinal upset, the nurse should provide which instruction?

"Take piroxicam with food or an antacid."

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

"The implant won't cure the virus, but it may help preserve your partner's vision. Not being able to see you or the surroundings may worsen your partner's dementia and make caring for your partner at home more difficult."

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

"The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient amounts of a factor that allows the vitamin to be absorbed."

A client with a new diagnosis of human immunodeficiency virus (HIV) tells the nurse, "I did not think drinks, dinner, and great sex would lead to a life-threatening disease." Which of the following is a therapeutic response by the nurse?

"This sounds distressing for you. What questions do you have?"

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

"What's your understanding about how HIV is transmitted?"

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

"You should speak with your healthcare provider about alternatives to taking cyclophosphamide."

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 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."

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.

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?

Administer epinephrine.

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

Alternate periods of activity with rest to decrease fatigue.

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

Decrease cardiac demands by promoting rest.

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

Notify the health care provider (HCP).

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

Pallor, tachycardia, and a sore tongue

The nurse is developing the plan of care for a client newly diagnosed with aplastic anemia. Which is a realistic goal for this client?

Perform activities of daily living without excessive fatigue or dyspnea.

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

Place latex-free, powder-free gloves at client's bedside.

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

Place sign on client's door reminding all persons to wash hands prior to entering.

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

Prevent infection.

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

A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?

Risk for injury

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?

anaphylactic reaction

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

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

applying pressure to the puncture site for a full 10 minutes

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

as soon as the needle is in the vein

A client is admitted with a suspected bacterial infection. What laboratory finding does the nurse apply as the best indication that the infection is in the acute phase?

immature neutrophils 12% on white blood cell differential

A client with rheumatoid arthritis is receiving antiinflammatory drugs and physical therapy. What is the expected outcome of these actions? The client will be able to:

manage joint pain and fatigue to perform activities of daily living.

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?

muscle cramps in the legs

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

normal saline solution as this is considered an isotonic solution

A client with iron deficiency anemia is taking iron supplements. What nutrient should the nurse instruct the client to take the supplements with in order to increase the absorption of iron?

orange juice

A 25-year-old client taking hydroxychloroquine for rheumatoid arthritis reports difficulty seeing out of their left eye. What does this finding indicate?

possible retinal degeneration

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

reduced sneezing

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

respiratory infection

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

sit upright, leaning slightly forward.

A client has moved into the acquired immunodeficiency syndrome (AIDS) phase of the human immunodeficiency virus (HIV) positive infection. The nurse advises the client to avoid what outdoor recreational activity?

swimming in rivers or lakes

A nurse applies standard precautions when caring for a client with human immunodeficiency virus (HIV). The nurse takes what action when applying standard precautions?

wearing gloves for providing mouth care

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."

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."

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'll need more genetic counseling in the future."

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

"You will feel a pulling type of discomfort for a few seconds."

A client with idiopathic thrombocytopenic purpura (ITP), an autoimmune disorder, is admitted to an acute care facility. Concerned about hemorrhage, the nurse monitors the client's platelet count and observes closely for signs and symptoms of bleeding. The client is at greatest risk for cerebral hemorrhage when the platelet count falls below:

10,000/μL.

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

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

A client with iron deficiency anemia is having trouble selecting food from the hospital menu.Which foods should the nurse suggest to meet the client's need for iron? Select all that apply

A client with iron deficiency anemia is having trouble selecting food from the hospital menu. Which food(s) should the nurse suggest to meet the client's need for iron? Select all that apply.

When a relief charge nurse posts assignments, a nurse notes that they are no longer assigned to a client whom the nurse has cared for the previous 2 nights. How should the nurse respond to this assignment?

Ask the nurse if there's a reason there was a change to the assignment.

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

Check for diminished sensations.

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

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?

Contact the health care provider at first signs of an infection.

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

Gradually increase activity tolerance.

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.

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?

"Every person is different. What works for one client may not always be effective for another."

The nurse has explained to a client with osteoarthritis how to use capsaicin cream. Which statement indicates the client has understood the nurse's explanation?

"I always wash my hands right after I apply the cream."

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

"I can eat whatever I want as long as it's low in fat."

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

Oral contraceptive use, pregnancy, and lactation increase daily requirements.

When a blood transfusion is terminated following a reaction, what action(s) must the nurse take? Select all that apply.

Send freshly-collected urine samples to the laboratory. Return the remainder of the blood component unit to the blood bank. Return the intravenous administration set to the blood bank. Alert the risk management department about the incident.

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

Stop the transfusion, infuse normal saline solution, and call the physician.

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?

Strictly adhere to antiviral medication therapy.

A client is taking nonsteroidal antiinflammatory drugs (NSAIDs) to manage pain from rheumatoid arthritis. What instruction should the nurse give the client about NSAIDs?

Take the prescribed medication with food and fluids.

The nurse is developing a teaching plan for women about human immunodeficiency virus (HIV) transmission. What should the nurse instruct the group about reducing the risk for transmission?

Use latex condoms with sexual intercourse.

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

Verify the physician's order.

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

Which laboratory test should the nurse monitor while the client is receiving heparin therapy?

activated partial thromboplastin time (APTT)

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

The nurse is assessing a client at risk for acute disseminated intravascular coagulation (DIC). Which finding indicates the client is showing an early sign of DIC?

bleeding without history or cause

During a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for which symptom?

early morning stiffness

A client with iron deficiency anemia is having trouble selecting food from the hospital menu. Which food(s) should the nurse suggest to meet the client's need for iron? Select all that apply.

eggs brown rice dark green vegetables oatmeal

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

fluid retention and weight gain.

The health care provider has prescribed interferon alfa-2b to treat a client with chronic hepatitis B. The nurse should assess the client for which common adverse effect?

flulike symptoms

A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse mostlikely to see?

hypercalcemia

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

quantification of T-lymphocytes.

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?

rotating the needle immediately after access

A client is newly diagnosed with pernicious anemia. The nurse is teaching the client to increase vitamin B12 intake. Which is the most effective way for this client to increase vitamin B12 intake?

taking vitamin B12 injections or nasal spray replacement

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

using only tampons at night