MED SURG

A nurse is collecting data from a client who is undergoing screening for breast cancer. Which of the following factors places the client at an increased risk for developing breast cancer?

Over 50 years of age

A nurse is caring for a client who is receiving chemotherapy to treat cancer. Which of the following adverse effects should the nurse anticipate from the chemotherapy?

Pancytopenia rationale: bone marrow suppression ( a deficiency of WBCs, RBCs, and platelet counts) is an expected adverse effect of chemotherapy.

A nurse is contributing to the plan of care for a client who has thrombocytopenia due to chemo therapy. Which of the following interventions should the nurse include?

Avoid IM injections rationale: A client who has thrombocytopenia is at risk for bleeding; therefore the nurse should avoid invasive procedure such as an IM injection.

A nurse is talking with a group of woman at a community center about the current recommendations for early detection of breast cancer. The nurse should recommend which of the following strategies?

begin annual mammograms at age 40

A nurse on an oncology unit is reinforcing discharge teaching with an adolescent client who received a bone marrow transplant for leukemia. Which of the following pieces of information should the nurse include?

- You should take your temperature at least once a day. -Examine your feet every day rationale: clients who are postoperative following bone marrow transplants are immunosuppressed and should continually monitor for manifestations of infection.

The nurse is preparing to administer an injection to a patient with a blood dyscrasia. To prevent bruising, how long should the nurse apply pressure to the injection site after administering the injection?

5 to 10 minutes rationale: To prevent bruising or hematoma formation in the patient with a blood dyscrasia, the nurse should apply pressure to the puncture site for 5 to 10 minutes after an injection or venipuncture. Applying pressure for less than 5 minutes may result in bleeding and holding pressure for longer than 10 minutes is not necessary.

A nurse is reinforcing teaching with a client about how to perform a breast self examination. The nurse should identify which of the following findings as an indication of breast cancer?

A nontender, hard lump that is palpated in a breast. rationale: cancerous tumors are typically hard, fixed, irregular in shape, and nontender to palpation. The nurse should instruct the client to notify the provider promptly if she palpates a hard, nontender lump.

The nurse is caring for a female patient whose sedimentation rate is 25 mm/h. What condition does the nurse suspect this patient to be experiencing?

An inflammatory process rationale: A sedimentation rate of 25 mm/h represents an abnormally high erythrocyte sedimentation rate, which is indicative of an infection or inflammatory process. A high sedimentation rate is not indicative of cancer, sickle cell trait, or an abnormal clotting time.

A patient has recently been diagnosed with cancer. What is the best initial nursing intervention for this patient?

Encourage the patient to verbalize feelings and fears. rationale: Soon after diagnosis, the patient should be encouraged to verbalize feelings and fears. The patient may be in a state of denial or anger, so introducing another cancer patient or providing literature would not be an initial intervention. Stating that "everything will work out fine" does not address the patient's feelings and instills false hope

A nurse is admitting a client who has multiple myeloma and a white blood cell count of 2,200/mm^3. Which of the following foods should the nurse prohibit the family members from bringing to a clietn?

Fresh fruit basket rationale: raw fruits and veggies are contraindicated for a client who has neutropenia, as the skin might harbor bacteria that can cause an infection. The nurse should prohibit these foods from entering the client's room.

The nurse caring for the patient with hemophilia should plan care that includes measures to manage which condition?

Hemarthrosis rationale: It is common for the patient with hemophilia to have hemarthrosis (bleeding into the joints). This condition is manifested with swelling and slight redness in the area of the joints. The nurse should anticipate that the patient may move more slowly and with obvious discomfort, and should plan care to manage these symptoms.

A nurse is contributing to the plan of care for a client who is postoperative following a modified radical mastectomy. Which of the following invasive devices should the nurse expect the client to have?

Jackson Pratt drain rationale: Jackson Pratt drains are placed under the skin flaps to promote drainage of fluid.

A nurse is caring for a client who is receiving brachytherapy. Which of the following measures should the nurse contribute to the client's plan of care?

Keep the door to the client's room closed. rationale: brachytherapy is a type of radiation therapy in which the radiation source is in direct contact with the client's tumor. During the therapy, the client emits radiation and is potentially hazardous to others. The client should be in a private room with a privatize bathroom, and the nurse should keep the door to the client's room closed.

The nurse is caring for a patient receiving chemotherapy as a treatment for his leukemia and notes an increase in uric acid level in his laboratory results. What intervention should the nurse include in this patient's plan of care?

Maintain adequate hydration rationale: An increased uric acid level sometimes results from rapid cell destruction during chemotherapy and can cause uric acid crystals to settle out in the kidney structures, causing impaired renal function. It is vitally important to maintain adequate hydration to prevent the crystals and impaired renal function. Although the physician should always be notified of abnormal laboratory results, the nurse should not hold the chemotherapy dose.

When studying the various types of cells, the student nurse correctly identifies which cells as providing cellular immunity?

T cells rationale: This is a type of acquired immunity essentially controlled by T lymphocytes. B lymphocytes change into plasma cells that produce immunoglobulins responsible for humoral immunity (e.g., antibody production, immune globulin function).

A nurse is caring for a client who has breast cancer and is receiving combination of chemotherapy medications. The client expresses confusion about the therapy. Which of the following explanations should the nurse provide?

The chemotherapy medications act at different stages of cell division so more tumor cells are destroyed. rationale: combining agents, medication therapy is more effective in stopping or slowing the growth of cancerous cells by interfering with their ability to multiply.

The nurse reviews the complete blood count results of a patient receiving chemotherapy and notes a platelet count of 100,000/mm3 of blood. The nurse is aware that this result indicates which condition?

Thrombocytopenia rationale: The normal platelet (thrombocyte) count is 150,000 to 400,000/mm3 of blood. Thrombocytopenia is an abnormally low number of platelets. Leukopenia refers to a low number of white blood cells (WBCs), aplastic anemia refers to deficient cell production due to a bone-marrow disorder, and agranulocytosis is a decrease in granulocyte production.

A nurse is reinforcing teaching with a client who has leukemia and has developed thrombocytopenia. Which of the following instructions should the nurse include in the teaching?

Use an electric razor when shaving rationale: using a razor to prevent nicks and cuts caused by conventional razors.

A nurse is collecting data from a client who has cancer of the cervix. Which of the following manifestations should the nurse expect?

Vaginal bleeding rationale: vaginal bleeding is the most common manifestation.

A nurse is collecting data from a client who has colorectal cancer. Which of the following manifestations should the nurse expect to find?

abdominal growth rationale: Clients who have colorectal cancer are likely to have changes in bowel habits, occult in blood in the stool, weight loss, fatigue, and "gas pains" or abdominal cramping.

A nurse is reinforcing discharge teaching with a client who is postoperative following a right mastectomy for breast cancer. The client will be going home with 2 Jackson Pratt drains. Which of the following pieces if information should the nurse include in the teaching?

avoid wearing deodorant until the drains are removed and incision heals. rationale: the nurse should instruct the client to avoid applying deodorants and talcum powder to the affected underarm until the drainage tubes are removed and the incision is healed.

The nurse is caring for a patient with sepsis who begins bleeding around his intravenous (IV) site. The bleeding continues despite pressure being applied to the site. What disorder should the nurse suspect is causing the bleeding?

- Disseminated intravascular coagulation rationale: DIC is a serious disorder that may be associated with diseases or disorders, such as severe trauma, gram-negative sepsis, shock, respiratory distress syndrome, malignancy, transfusion reaction, amniotic embolus, and abruptio placentae. The first signs of DIC are usually continuous bleeding from an injection or IV site, extensive bruising in areas of injury, ecchymoses where there has been no trauma, and petechiae. There may also be oral, vaginal, or rectal bleeding.

The nurse is preparing to care for a patient with sickle cell anemia. The nurse knows which statement(s) is(are) true of sickle cell anemia? (Select all that apply.

- it is hereditary -it is the result of abnormal hemoglobin rationale: Sickle cell anemia results from the hereditary production of abnormal hemoglobin. Increased oxygen demand causes classic symptoms (e.g., shortness of breath, joint pain). As with all anemias, this disorder results in lower than normal hemoglobin levels.

Major measures to help prevent cancer in patients should be taught by the nurse at every given opportunity. What are those things that should be taught to patients about the prevention of cancer? (Select all that apply.

- maintain a normal weight - abstain from nitrite and nitrate food additives. -have your drinking water supply checked for contaminants. rationale: Major measures to help prevent cancer in patients should be taught by the nurse at every given opportunity. Those things that should be taught to patients about the prevention of cancer include moderation in drinking alcohol, increasing (not decreasing) ascorbic acid (vitamin C), maintenance of normal weight, checking the chemical makeup of the local water supply, and avoiding nitrite and nitrate food additives.

The nurse is planning care for the patient hospitalized with sickle cell crisis. What is the priority nursing intervention?

Controlling pain rationale: The priority intervention for the patient in sickle cell crisis is pain control. The defective S hemoglobin of the disease forms clumps in the red blood cells; causing them to assume a sickle shape, block blood vessels, break apart, and form thrombi that cause organ and tissue damage. Managing fatigue and preventing infection are also interventions for a sickle cell patient but are not the priorities during a crisis. Promoting rest is also an intervention during crisis.

A nursing assistant says to the LPN/LVN, "I can't believe that Mrs. Feld, who is so sick and so near death, still enjoys a good laugh." Which of these ideas should the nurse use as the basis for discussing Mrs. Feld's behavior?

Humor is a healthful part of everyone's life. rationale: Humor is a healthy way to deal with stress, even during a terminal illness, as long as it is welcomed by the patient. This behavior does not indicate that she is suicidal or show an inability to face reality. As long as the patient enjoys humor, the assistant should encourage it.

A nurse is caring for a postoperative client whose surgeon informed him of a metastasizing malignant neoplasm in the colon. Which of the following statements indicates that the client understands this information?

I have cancer of the colon that has begun to spread rationale: a neoplasm is a continued growth of nonessential cells, and the term "malignant" means that these cells are cancerous.

A patient who has been prescribed an antineoplastic drug for his newly diagnosed cancer asks the nurse what the most common side effect is for these drugs. What is the nurse's most accurate response

Most of these drugs cause some degree of bone-marrow depression." rationale: All antineoplastic drugs cause bone-marrow depression. The degree of bone-marrow depression depends on the drug and dosage. Gastrointestinal upset is experienced with some neoplastic drugs. An elevated temperature is a sign of infection, and vitamin B12 deficiency is not commonly a side effect.

A nurse is collecting a health history from a client who has skin cancer. Which of the following findings in the client's history is the highest risk factor for developing cancer?

Overexposure to sunlight

A patient who is near death has the following nursing diagnosis—Impaired gas exchange related to fluid in the lungs. Which intervention is most appropriate?

Place the patient in the Fowler position rationale: When patients are near death, they often subjectively feel as if they cannot get enough air. Placing the patient in the Fowler position will help prevent aspiration of mucus and fluids produced during the dying process. Suctioning is uncomfortable and will stimulate more mucus and fluid production by irritating the mucosa. Pursed-lip breathing and coughing will not decrease the mucus and fluid production and would be exhausting to the dying patient.

The husband of the patient with leukemia states, "The physician just told me the chemo didn't work and there's nothing left to try. That means my wife is going to die." What is the nurse's best response?

That must have been so hard for you rationale: This is an open-ended response, allowing the patient's husband to verbalize his concerns. This response also acknowledges his feelings and demonstrates empathy. The nurse's focus should be on the patient's husband and his needs, not on the nurse's, as "I didn't know that" implies.

A nurse is assisting in planning care for a client who has cancer and has developed thrombocytopenia following chemotherapy. Which of the following precautions should the nurse offer to minimize the adverse effects of thrombocytopenia?

remind the client to use an electric razor. rationale: institute bleeding precautions which includes the use of an electric razor

A nurse is collecting data from a client. Which of the following findings is the highest risk factor for the client developing bladder cancer?

The client uses tobacco.

The patient with anemia asks the nurse why her doctor has prescribed an iron preparation for her. Which response by the nurse is most accurate?

The iron will help your body manufacture hemoglobin rationale: Iron will help the anemic patient with the synthesis of hemoglobin. Iron will not prevent hemorrhage or help synthesize plasma and antibodies, and it is not prescribed for the prevention of sepsis.

A patient undergoes chemotherapy and loses her hair. Which of these findings is most indicative that the patient has satisfactorily adjusted to her alopecia?

The patient purchases scarves in varying colors. rationale: The patient purchasing scarves in varying colors would be indicative that the patient is coming to terms about her hair loss. Buying a wig, washing her remaining hair, and visiting another person with hair loss are also positive actions following alopecia. Verbalizing steps in the grief process does not indicate acceptance of alopecia.

A patient who is to receive vitamin B12 injections for treatment of pernicious anemia asks the nurse how long she will have to receive these injections. Which response by the nurse is correct?

You will need the injection for the rest of your life." rationale: Patients with pernicious anemia are unable to produce the intrinsic factor, which is secreted in the stomach. The intrinsic factor is necessary for the absorption of B12; therefore, the patient will need lifetime injections of B12 on a schedule prescribed by the primary care provider.

A nurse is caring for a client who is receiving radiation therapy for breast cancer and reports a metallic taste in the mouth. Which of the following dietary recommendations should the nurse relay?

offer mints rationale: mints overcome the metallic taste

A nurse is contributing to the plan of care for a client who has cancer and is scheduled to receive internal radiation therapy. Which of the following actions should the nurse recommend?

place the client in a private room. rationale: the nurse should recommend placing the client in a private room during internal radiation therapy to prevent exposing other clients and visitors to radiation.

A nurse is reinforcing preoperative teaching with a client who has colorectal cancer and is scheduled to undergo placement of colostomy with a perineal wound. Which of the following statements by the client indicates an understanding of the teaching?

" I can have only liquids for 2 days before the surgery." rationale: client should consume a full or clear liquid diet for 24 to 48 hours before the surgery to decrease bulk.

The nurse is providing patient teaching for a patient with thrombocytopenia. What should the nurse advise the patient to avoid? (Select all that apply.

-aspirin -contact sports -anticoagulant therapy -nonsteroidal anti-inflammatory drugs rationale: Contact sports increase risk of injury and subsequent bleeding. Anticoagulant therapy would obviously be contraindicated in a patient who already has difficulty clotting. Aspirin and NSAID use carry a high risk of gastrointestinal irritation, ulcers, and bleeding. Iron supplements would have no effect on thrombocytopenia or its management.

The student nurse is studying the hematologic system. The student is correct when listing which element(s) as being necessary for erythropoiesis to occur? (Select all that apply.)

- iron - folic acid - Vitamin C - Vitamin B12

A patient is scheduled to receive external radiation therapy. Which potential side effects should the nurse include in patient teaching points? (Select all that apply.)

-fatigue -loss of taste -skin reaction at site of exposure rationale: External radiation therapy has far fewer side effects than it did in the past, but it does include skin reaction (change in texture and/or color; moist desquamation [rare]), loss of taste, and fatigue. Mental slowness is not a side effect of external radiation therapy. Contamination to others can occur with internal radiation therapy.

A 56-year-old man was recently diagnosed with multiple myeloma. Which diagnostic procedure will the nurse most likely have performed initially?

Obtaining complete blood count with differential and Bence-Jones protein levels in the urine rationale: Essential information can first be obtained with the 24-h urine collection for Bence-Jones protein. Serum electrolytes are helpful in evaluating circulating calcium levels, but Bence-Jones protein is the definitive diagnostic tool for multiple myeloma. WBC differential may indicate the specific leukocyte affected. Although this diagnostic test is used to evaluate bone-marrow function, it would not be the one used initially. It is highly invasive and is accompanied by a significant risk of bleeding. Although serum calcium levels need to be evaluated in a patient with multiple myeloma, ABGs are of little benefit unless the patient is showing signs of dyspnea.

A patient is receiving hormone therapy for treatment of breast cancer. The nurse should inform the patient that she is at high risk for the development of which of these serious effects

Venous thromboembolism rationale: Women receiving estrogens or progestins may have irregular menses, fluid retention, and breast tenderness. All patients who take estrogen or progestins are at increased risk for venous thromboembolism (VTE). Androgens and the antiestrogen receptor drugs cause masculinizing effects in women. Chest and facial hair may develop, menstrual periods stop, and breast tissue shrinks. VTE is the most serious side effect of use of hormone therapy.

A 36-year-old mail carrier with a history of anemia tells the nurse she made an appointment with her physician because she has "been having trouble getting through the day lately." What symptom would you expect the patient to report?

shortness of breath rationale: Shortness of breath is a common complaint that results from decreased oxygen-carrying capacity of red cells. Enlarged lymph nodes, nausea and vomiting are not associated with anemia. Fatigue occurs with increased oxygen demand; it would occur and worsen as the day's activities progressed.

A nurse is contributing to the plan of care for a client who is receiving chemotherapy and has protein deficiency. Which of the following interventions should the nurse include inn the plan of care?

- mix powdered skim milk into milk. -add a slice of cheese to hot vegetables -mix yogurt into fresh fruit. rationale: diary products are good source of protein.

A nurse is caring for a postmenopausal client who is concerned that she might have higher than average risk of breast cancer. After collecting data from the client, the nurse should identify which of the following factors as increasing her breast cancer risk?

-increased breast density. -BMI 32 -Hormonal replacement therapy for 10 years.

A nurse is caring for a client who recently had chemotherapy and now has myelosuppression. Which of the following interventions should the nurse initiate?

-prohibit bringing fresh flowers and plants into the client's room. -ensure thorough cleaning of the client's room and bathroom daily. -use dedicated equipment items such as stethoscopes. rationale: myelosuppression is bone marrow depression, which puts the clients at HIGH risk of infection after chemotherapy.

The nurse is caring for an African American patient who has a diagnosis of thrombocytopenia purpura. When performing a physical assessment on this patient, where is(are) the best place(s) for the nurse to assess for the presence of petechiae? (Select all that apply.)

-soles of the feet -palms of the hands rationale: Petechiae are small, red pinpoint lesions that occur with this hemorrhagic disease. In dark-skinned people, petechiae are more visible on the palms of the hand and the soles of the feet. Bruising is also characteristic of this disease and appears as dark areas on dark-skinned people.

A patient who is in the terminal stages of his illness says to the LPN/LVN, "Get out of here! You do everything so slowly. Leave me alone!" Which of these responses by the nurse is most appropriate?

You sound very angry today. rationale: Anger is one of the stages of grieving. By saying, "You sound angry today," the nurse acknowledges the patient's feelings without placing the patient on the defensive. This statement will allow the patient to further explore his feelings with the nurse. The statements, "You cannot talk to me that way," and "I'm leaving until you stop being so angry," will cause the patient to be defensive and are not therapeutic communication techniques. Apologizing to the patient about the way the nurse works does not acknowledge the real issue.

A nurse is collecting data from a client who has cancer and is receiving chemotherapy by peripheral IV infusion. The client reports pain at the insertion site, and the nurse notes fluid leaking around the catheter. Which of the following actions should the nurse take first?

stop the infusion.

A patient is scheduled for a computed tomography (CT) scan. To prepare the patient appropriately, the nurse should provide the patient with which information?

the test is noninvasive rationale: CT scans are a noninvasive radiologic method of providing diagnostic information. A small surgical incision would be necessary for a biopsy; magnetic resonance imaging involves a powerful magnet; and an endoscopic procedure provides direct visualization of an organ.

A nurse is caring for a client who has testicular cancer and experiencing peripheral neuropathy as an adverse effect of chemotherapy. Which of the following client manifestations is an expected finding of peripheral neuropathy?

tingling of hands and feet. rationale: major manifestations of peripheral neuropathy is numbness and tingling of an extremity.

A nurse is caring for a client who is receiving radiation therapy for mouth cancer and reports a dry mouth. Which of the following dietary recommendations should the nurse provide?

use gravies or sauces to soften food. rationale: gravies or sauces help make foods easier to eat.

A nurse is planning a presentation for a group of older adults at a senior community center about risk factors for cancer. Which of the following factors increases the risk of developing cancer after age 60?

weakened immune responses rationale: after age 60, people are at higher risk for cancer due to hormonal changes, altered immune responses, and accumulation of free radicals. Age itself is a significant factor because the longer people have exposure to external carcinogenic factors.

A nurse is reinforcing a postoperative discharge teaching with a client following a pan hysterectomy for uterine cancer. Which of the following pieces of information should the nurse provide?

you might experience manifestations of menopause. rationale: the nurse should inform the client that the following a panhysterrectomy, pregnancy is not possible, and birth control is no longer required.

A nurse is reinforcing teaching with a client who has cancer and is undergoing external radiation treatment. Which of the following statements by the client indicate an understanding of the teaching?

" I should use my hand instead of a washcloth to wash the areas of being radiated." rationale: It is gentler to wash the areas being radiated with the hand instead of the washcloth.

A nurse is reinforcing discharging teaching with a client following open radical prostatectomy. The client is going home with an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?

" I will take acetaminophen if i have any pain" rationale: avoid aspirin and NSAIDS for least 2 week after surgery to prevent risk of bleeding.

A nurse is reinforcing teaching with a client who has cancer and is receiving external radiation therapy. Which of the following statements made by the client indicates an understanding of the teaching?

I need to protect the area from sunlight.

A nurse is reinforcing teaching with a client who has stomatitis due to chemotherapy. Which of the following statements by the client indicates a need for further instructions?

I will cleanse my mouth after meals with an alcohol based mouthwash. rationale: clients who have stomatitis should avoid the use of alcohol based mouthwash because it can irritate and burn the mucous membranes.

A nurse is planning care for a client who is postoperative following a urinary diversion to treat bladder cancer. Which of the following interventions should the nurse include in the plan of care?

change the collection pouch in the early morning rationale: collect when the clients urine output is reduced

A nurse is caring for a client who will receive brachytherapy to treat uterine cancer. The nurse should ensure the client understands that she will receive which of the following interventions?

radioactive infusions or insertions into or near the tumor. rationale: brachytherapy is type of radiation therapy during which the radiation source is either an implant or via infusion is in direct contact with the client's tumor continuously for a specific duration.

A charge nurse is observing a newly licensed nurse provide care for a client. The client is receiving internal radiation therapy for the treatment of cervical cancer. Which of the following actions by the newly licensed nurse should prompt the charge nurse to intervene?

Borrowing a dosimeter film badge from another nurse before entering the client's room. rationale: a nurse should never borrow a dosimeter film badge from another staff member. Nurses who are caring for the client should each have persona badge. the badge must be worn any time the nurse is in the client's room to measure the radiation exposure that the nurse is receiving. Each film badge will indicate the nurse's cumulative radiation exposure.

A hospice nurse is reinforcing teaching about palliative care to the partner of a client who has end stage liver cancer. Which of the following statements by the partner indicates an understanding of teaching?

I will continue to talk to him, even when he's sleeping. rationale: hearing is thought to be the last sense lost in the dying process's therefore the partner should continue to communicate with the client.

A nurse is assisting with planning of care for a client who is postoperative following a radical mastectomy. Which of the following interventions should the nurse include in the plan?

begin exercises with the client one day after the procedure. rationale: the nurse should plan to begin exercises that do not stress the incision on the first postoperative day to promote lymphatic return and mobility.

A patient with hemophilia is complaining of a headache. What does the nurse suspect may be occurring with this patient?

bleeding into intracranial spaces rationale: The hallmark of hemophilia is bleeding into joints, causing loss of mobility and unequal extremity lengths. Bleeding also occurs internally, with leakage of blood into the intestinal wall or peritoneal cavity, and into the deeper tissues of the body. Hemarthrosis is the primary problem for most patients with hemophilia. If the bleeding occurs in the intracranial spaces and thereby increases intracranial pressure, the patient may experience convulsions and brain damage that can be fatal. Hemophilia medications do not typically cause headaches. Elevated WBC levels are not an effect of hemophilia. Bone-marrow biopsies are not used to diagnose hemophilia.

A client who has stage 2 breast cancer asks the nurse about sites of metastasis for this cancer. Which of the following responses should the nurse make?

breast cancer tends to metastasize to the bones. rationale: common sites of breast cancer metastasis are the bones, lungs, brain and liver.

A nurse in an oncology clinic is collecting data from a client who has early stage of Hodgkin's lymphoma. Which of the following findings should the nurse expect?

enlarged lymph nodes rationale: enlarged lymph nodes is the first manifestation of this cancer.

A nurse is caring for a client who has lung cancer that has metastasized. Which of the following findings indicates the client is developing superior vena cava syndrome?

facial edema rationale: superior vena cava syndrome is medical emergency resulting from a partial occlusion of the superior vena cava, leading to decreased blood flow through vein. Most cases of superior vena cava syndrome are associated with cancers involving the client's upper chest, such as advance lung and breast cancers and lymphoma. The earliest manifestations of superior vena cava syndrome are facial and upper extremity edema. Death can result if the compression is not corrected.

A patient has been admitted to the hospital with a diagnosis of sickle cell crisis. What is the primary focus nursing interventions for this patient?

pain control rationale: Pain control is important for patients with sickle cell anemia in crisis. The patient will also be ordered to have oxygen via nasal cannula. Bleeding precautions are associated with disorders causing low platelet counts. Protective isolation is associated with disorders affecting leukocytes. Occult blood in the stool is associated with gastrointestinal bleeding.

A patient has severe anemia and is given a blood transfusion. Which symptom should the LPN/LVN report immediately if it occurs during the transfusion?

pain in the lower back rationale: Hemolysis occurs as the result of a blood transfusion reaction. Signs and symptoms of a reaction include chills, fever, low back pain, flushing, tachycardia, tachypnea, hypotension, vascular collapse, hemoglobinuria, acute jaundice, dark urine, bleeding, acute renal failure, shock, cardiac arrest, and death.

A nurse is planning presentation in a community center about risk factors for cancer. Which of the following types of cancer should the nurse include when discussing familial clustering of specific types of cancer?

prostate rationale: types of cancers that typically demonstrate a familial tendency include breast, colorectal, ovarian, and prostate.