Immune and Hematologic Disorders
A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information? Advanced medical intervention can cure most autoimmune disorders. Autoimmune disorders include connective tissue (collagen) disorders. Autoimmune disorders are distinctive, aiding differential diagnosis. Clients with autoimmune disorders may have false-negative but not false-positive serologic tests.
Autoimmune disorders include connective tissue (collagen) disorders. Explanation: Connective tissue disorders are considered autoimmune disorders. Clients with autoimmune disorders may have either false-positive or false-negative serologic tests for syphilis. Other common laboratory findings in these clients include Coombs-positive hemolytic anemia, thrombocytopenia, leukopenia, immunoglobulin excesses or deficiencies, antinuclear antibodies, antibodies to deoxyribonucleic acid and ribonucleic acid, rheumatoid factors, elevated muscle enzymes, and changes in acute phase-reactive proteins. No cure exists for autoimmune disorders; treatment centers on controlling symptoms. Autoimmune disorders aren't distinctive; they share common features, making differential diagnosis difficult.
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? cold compresses to joints for 30 minutes to relieve stiffness aspirin after activity to decrease inflammation a warm shower before performing activities of daily living a 4.5-kg (10-lb) weight loss to limit stress on joints
a warm shower before performing activities of daily living Explanation: Warm showers, baths, or hand soaks can help relieve joint stiffness and allow the client to more comfortably perform activities of daily living. Aspirin or other anti-inflammatory drugs should be taken before activity, not after, to help decrease inflammation and reduce joint pain and inflammation. Although weight loss may decrease stress on joints, pain and stiffness will continue to be a problem. Cold compresses are most effective for relieving joint pain, whereas moist heat is useful for decreasing pain and stiffness. When cold compresses are applied, their use should be limited to 10 to 15 minutes at a time to decrease the risk for tissue damage.
A mother asks the nurse if her child's iron-deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which of the following? Children with iron-deficiency anemia are equally as susceptible to infection as are other children. Little is known about iron-deficiency anemia and its relationship to infection in children. Children with iron-deficiency anemia are more susceptible to infection than are other children. Children with iron-deficiency anemia are less susceptible to infection than are other children.
Children with iron-deficiency anemia are more susceptible to infection than are other children. Explanation: Children with iron-deficiency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis
A physician orders gentamicin sulfate, 80 mg I.V. every 8 hours for a client with Pseudomonas aeruginosa. The nurse should infuse this drug over at least: 10 minutes. 30 minutes. 20 minutes. 5 minutes.
Explanation: The nurse should infuse gentamicin sulfate I.V. over at least 30 minutes. Infusing the drug more rapidly may increase the client's risk of adverse reactions.
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? Obtain sufficient exercise. Maintain fluid balance. Avoid depression. Prevent infection.
Prevent infection. Explanation: The client with Hodgkin lymphoma who has had radiation therapy is prone to infection; therefore, the primary goal is to prevent infection. The nurse instructs the client to perform frequent hand hygiene, avoid crowded areas, and report a temperature over 100°F (37.7°C). Maintaining fluid balance, exercising, and maintaining mental health are also important, but these are not primary goals at this time.
A nurse is assigned to a client with acquired immunodeficiency syndrome (AIDS). The nurse takes what precautions? The nurse uses the same precautions as with any client. The nurse dons gloves for all direct contact with the client. The nurse uses isolation precautions specific to viral illnesses. The nurse ensures barrier protection from all client body fluids.
The nurse uses the same precautions as with any client. Explanation: Standard precautions are implemented for contact with all clients, including those who are known to be HIV positive. The client with HIV requires no special precautions. Not all body fluids are a risk for transmission of HIV; only blood, sexual fluids, and breast milk transmit the virus. The nurse does not have to avoid contact with tears, sweat, or saliva. There are no precautions "specific to viral illnesses," because different viruses transmit in various ways.
The nurse has received a bag of platelets from the pharmacy and is preparing to administer them to a client. Which finding indicates that the nurse should contact the pharmacist? The platelet bag is 2 days old. The platelet bag is at room temperature. The platelet bag is 12 hours old. The platelet bag is cold.
The platelet bag is cold. Explanation: Platelets cannot survive cold temperatures. The platelets should be stored at room temperature and last for no more than 5 days.
The nurse is caring for a client diagnosed with idiopathic thrombocytopenia purpura (ITP). The nurse includes what intervention? teaching the client to avoid brushing teeth to avoid gum trauma and bleeding monitoring daily international normalized ratio (INR) for bleeding risk administering platelets as prescribed to maintain an adequate platelet count administering stool softeners as prescribed to prevent straining during defecation
administering stool softeners as prescribed to prevent straining during defecation Explanation: The nurse should take measures to prevent bleeding because the client with ITP is at increased risk for bleeding. Straining at stool causes the Valsalva maneuver, which may raise intracranial pressure, thus increasing the risk for intracerebral bleeding. To prevent straining, the nurse should give stool softeners to prevent straining that may result from constipation. Although teaching the client to avoid brushing teeth would be inappropriate, the nurse can encourage the use of a soft toothbrush. Platelets rarely are transfused prophylactically in clients with ITP, because the cells are destroyed, providing little therapeutic benefit. ITP will not directly affect the client's INR level, which measures clotting factor activity, not platelet level.
Which clients will the nurse place in reverse isolation? Select all that apply. client with a burn injury involving > 30% of the total body surface area (TBSA) client with viral hemorrhagic fever client with a white blood cell count (WBC) of 600 µL with a granulocyte count of 100 µL client with chickenpox client with human immunodeficiency virus (HIV)
client with a white blood cell count (WBC) of 600 µL with a granulocyte count of 100 µL client with a burn injury involving > 30% of the total body surface area (TBSA) Explanation: Reverse or protective isolation is used for clients with diseases and conditions in which there is increased susceptibility to infection such as clients with neutropenia, clients receiving chemotherapy, severely immunocompromised clients, and burn clients. Client isolation techniques attempt to break the chain of infection by interfering with transmission.
A client with aplastic anemia is instructed to eat foods rich in iron. The nurse should instruct the client to include which food in the diet to increase iron intake? dark green leafy vegetables fresh fruits cheese chicken breasts
dark green leafy vegetables Explanation: Foods high in iron include dark green leafy vegetables, liver and red meat, eggs, dried fruit, legumes, and whole grain breads.Fruits, cheese, and chicken are not high in iron.
A multidisciplinary oncology team of health care providers, nurses, and the social worker notes that a client who has been undergoing chemotherapy is now experiencing pancytopenia. When reviewing the laboratory data, which values support this diagnosis? Select all that apply. increased platelets increased white blood cells decreased RBCs decreased white blood cells increased RBCs decreased platelets
decreased white blood cells decreased platelets decreased RBCs Explanation: Pancytopenia is a deficiency of all blood cells that includes a state of simultaneous leukopenia (decreased white blood cells), thrombocytopenia (decreased platelets), and anemia (decreased RBCs). Pancytopenia has widespread effects on the body by leading to oxygen shortage and immune function.
The nurse is teaching a client with osteoarthritis when to take ibuprofen to minimize gastric mucosal irritation. What time is best? immediately after a meal on an empty stomach on arising at bedtime
immediately after a meal Explanation: Drugs that cause gastric irritation, such as ibuprofen, are best taken after or with a meal, when stomach contents help minimize the local irritation. Taking the medication on an empty stomach at any time during the day will lead to gastric irritation. Taking the drug at bedtime with food may cause the client to gain weight, possibly aggravating osteoarthritis. When the client arises, they are stiff from immobility and should use warmth and stretching until they get food in the stomach.
A client with a history of type 1 diabetes mellitus and chronic obstructive pulmonary disease should have which immunization? influenza hepatitis A varicella measles-mumps-rubella
influenza Explanation: The client with diabetes and a chronic respiratory condition is most at risk for influenza and should receive the vaccine yearly. Diabetes and chronic respiratory conditions do not increase the risk of hepatitis A. An adult client is not as likely to need the measles-mumps-rubella or varicella immunizations, but titers can be checked if the client has not had childhood immunizations or the disease.
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to sit upright, leaning slightly forward. lie supine with their neck extended. hold their nose while bending forward at the waist. blow their nose and then put lateral pressure on their nose.
sit upright, leaning slightly forward. Explanation: Sitting upright and leaning slightly forward avoids increasing vascular pressure in the nose and helps the client avoid aspirating blood. Lying supine won't prevent aspiration of the blood. Nose blowing can dislodge any clotting that has occurred. Bending at the waist increases vascular pressure in the nose and promotes bleeding rather than halting it.
The nurse is teaching a client about preventing toxic shock syndrome (TSS). Which action is a risk factor for toxic shock syndrome? changing tampons every 3 hours using only tampons at night alternating tampons with sanitary pads avoiding use of deodorized tampons
using only tampons at night Explanation: Risk factors for TSS include the use of tampons at night, when the tampon would be in place for 7 to 9 hours. TSS can occur in other situations, but it is commonly associated with women during menses, particularly women who use tampons. The longer the tampon is left in place, the greater the risk for TSS. Changing tampons every 3 hours or more frequently, avoiding use of deodorized tampons, and alternating tampons with sanitary pads are actions that decrease the risk of TSS.
The client with rheumatoid arthritis tells the nurse, "I have a friend who took gold shots and had a wonderful response. Why didn't my health care provider (HCP) let me try that?" Which response by the nurse would be most appropriate? "It's the HCP's prerogative to decide how to treat you. They have chosen what is best for your situation." "Every person is different. What works for one client may not always be effective for another." "Tell me more about your friend's arthritic condition. Maybe I can answer that question for you." "That drug is used for cases that are more advanced than yours. You're not eligible for this treatment now."
"Every person is different. What works for one client may not always be effective for another." Explanation: The nurse's most appropriate response is one that is therapeutic. The basic principle of therapeutic communication and a therapeutic relationship is honesty. Therefore, the nurse needs to explain truthfully that each client is different and that there are various forms of arthritis and arthritis treatment. To state that it is the HCP's prerogative to decide how to treat the client implies that the client is not a member of their own health care team and is not a participant in their care. The statement also is defensive, which serves to block any further communication or questions. Asking the client to tell more about the friend presumes that the client knows correct and complete information, which is not a valid assumption to make. The nurse does not know about the client's friend and should not make statements about another client's condition. Stating that the drug is for advanced disease demonstrates that the nurse is making assumptions that are not necessarily valid or appropriate. Also, telling the client that they are not eligible for the drug now is not within the scope of the nurse's practice.
A client with rheumatoid arthritis is being discharged with a prescription for aspirin, 600 mg P.O. every 6 hours. Which statement by the client indicates understanding of the adverse effects of the medication? "I know this medication may cause constipation so I will take a daily stool softener." "I'll call my physician if I have difficulty voiding." "I'll call my physician if I have ringing in the ears." "I know this mediation may cause bleeding so I will take it on an empty stomach."
"I'll call my physician if I have ringing in the ears." Explanation: The client with rheumatoid arthritis typically takes a relatively high dosage of aspirin for its anti-inflammatory effect. The nurse should instruct the client to report signs and symptoms of aspirin toxicity, such as tinnitus (ringing in the ears). Dysuria and constipation are not associated with aspirin use or toxicity. Bleeding is, so the client is instructed to take with food.
A 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? "Stiffness and pain are part of the disease. Learn to cope by focusing on activities you enjoy." "Take a warm tub bath or shower before exercising. This may help with your discomfort." "You're probably exercising too much. Decrease your exercise to every other day." "Tell the health care provider about your symptoms. Maybe your analgesic medication can be increased."
"Take a warm tub bath or shower before exercising. This may help with your discomfort." Explanation: Superficial heat applications, such as tub baths, showers, and warm compresses, can be helpful in relieving pain and stiffness. Exercises can be performed more comfortably and more effectively after heat applications. A client with rheumatoid arthritis must balance rest with exercise every day, not every other day. Typically, large doses of analgesics, which can lead to hepatotoxic effects, are not necessary. Learning to cope with the pain by refocusing is inappropriate.
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." "If my fiancé was of Middle Eastern descent, I wouldn't be worried about having children." "I need to learn how to give myself vitamin B12 injections." "We should never plan to have children."
"We'll need more genetic counseling in the future." Explanation: Two people with the beta-thalassemia trait have a 25% chance of having a child with thalassemia major, a potentially life-threatening disease. Vitamin B<!sub>12!sub> injections are used to treat pernicious anemia, not thalassemia. Thalassemia occurs primarily in people of Italian, Greek, African, Asian, Middle Eastern, East Indian, and Caribbean descent. The client needs to know the risks before starting a family.
A client is admitted to the facility with an exacerbation of chronic systemic lupus erythematosus (SLE). The client gets angry when the call bell isn't answered immediately. What is the nurse's most appropriate response? "I am sensing that you would like to talk about the problem, I will get the nursing supervisor to speak with you." "I know this is difficult for you but you should calm down. You know that stress will make your symptoms worse." "I can see you're angry but there is a lot going on right now. Please be patient and I will be back when I can." "You seem angry. Would you like to talk about it?"
"You seem angry. Would you like to talk about it?" Explanation: Verbalizing the observed behavior is a therapeutic communication technique in which the nurse acknowledges what the client is feeling. Offering to listen to the client express anger can help both the nurse and the client understand its cause and begin to deal with it. Although stress can exacerbate the symptoms of SLE, telling the client to calm down doesn't acknowledge the client's feelings. Offering to get the nursing supervisor also ignores the client's feelings. Ignoring the client's feelings by leaving suggests that the nurse has no interest in what the client has said.
A client is about to undergo bone marrow aspiration of the sternum. What should the nurse tell the client? "After the needle is removed, you will feel a bandage being applied around your chest." "You will feel a pulling type of discomfort for a few seconds." "You will not feel the local anesthetic being applied because it will be sprayed on." "You may feel a solution being wiped over your entire front from your neck down to your navel and out to your shoulders."
"You will feel a pulling type of discomfort for a few seconds." Explanation: As the bone marrow is being aspirated, the client will feel a suction or pulling type of sensation or discomfort that lasts a few seconds. A systemic premedication may be given to decrease this discomfort. A small area over the sternum is cleaned with an antiseptic. It is unnecessary to paint the entire anterior chest. The local anesthetic is injected through the subcutaneous tissue to numb the tissue for the larger-bore needle that is used for aspiration and biopsy. After the needle is removed, pressure is held over the aspiration site for 5 to 10 minutes to achieve hemostasis. A small dressing is applied; a large pressure dressing, such as an Ace bandage, would restrict the expansion of the lungs and is not used.
A client is about to undergo bone marrow aspiration of the sternum. What should the nurse tell the client? "You will not feel the local anesthetic being applied because it will be sprayed on." "You may feel a solution being wiped over your entire front from your neck down to your navel and out to your shoulders." "You will feel a pulling type of discomfort for a few seconds." "After the needle is removed, you will feel a bandage being applied around your chest."
"You will feel a pulling type of discomfort for a few seconds." Explanation: As the bone marrow is being aspirated, the client will feel a suction or pulling type of sensation or discomfort that lasts a few seconds. A systemic premedication may be given to decrease this discomfort. A small area over the sternum is cleaned with an antiseptic. It is unnecessary to paint the entire anterior chest. The local anesthetic is injected through the subcutaneous tissue to numb the tissue for the larger-bore needle that is used for aspiration and biopsy. After the needle is removed, pressure is held over the aspiration site for 5 to 10 minutes to achieve hemostasis. A small dressing is applied; a large pressure dressing, such as an Ace bandage, would restrict the expansion of the lungs and is not used.
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. Provide respiratory support with bag-valve mask. Administer albuterol (salbutamol). Establish intravenous access.
Administer epinephrine. Explanation: To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent adrenergic agonist, as ordered. The healthcare provider is likely to order additional medications, such as antihistamines and corticosteroids; if these medications do not relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client. The nurse should continue to monitor the client's vital signs; a client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring. However, administering epinephrine is the first priority.
The nurse is administering packed red blood cells (PRBCs) to a client. What should the nurse do first? Stay with the client during the first 15 minutes of infusion. Administer the PRBCs through a percutaneously inserted central catheter line with a 20-gauge needle. Discontinue the intravenous (IV) catheter if a blood transfusion reaction occurs. Flush PRBCs with 5% dextrose and 0.45% normal saline solution.
Stay with the client during the first 15 minutes of infusion. Explanation: The most likely time for a blood transfusion reaction to occur is during the first 15 minutes or first 50 mL of the infusion. If a blood transfusion reaction does occur, it is imperative to keep an established IV line so that medication can be administered to prevent or treat cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-gauge or larger needle; a peripherally inserted central catheter line is not recommended to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer's solution and should be infused with only normal saline solution
A client is having a blood transfusion reaction. What must the nurse do in order of priority from first to last? All options must be used. Stop the transfusion. Complete the appropriate transfusion reaction form(s). Notify the health care provider (HCP) and blood bank. Keep the intravenous (IV) line open with normal saline infusion.
Stop the transfusion. Keep the intravenous (IV) line open with normal saline infusion. Notify the health care provider (HCP) and blood bank. Complete the appropriate transfusion reaction form(s). Explanation: When the client is having a blood transfusion reaction, the nurse should first stop the transfusion and then keep the IV open with a normal saline infusion. Next, the nurse should notify the HCP and blood bank and then complete the required form(s) regarding the transfusion reaction.
The nurse is assisting with a bone marrow aspiration and biopsy. Place the tasks in the order in which the nurse should perform them, from highest priority to least priority. All options must be used. 1-Apply ice to the biopsy site. 2-Clean the skin with an antiseptic solution. 3-Position the client in a side-lying position. 4-Verify the client has signed an informed consent. SUBMIT ANSWER Exit quiz
Verify the client has signed an informed consent. Position the client in a side-lying position. Clean the skin with an antiseptic solution. Apply ice to the biopsy site. Explanation: First, before the procedure begins, the nurse must verify that the client understands the procedure and has voluntarily signed a consent form. The nurse should then position the client in a side-lying, or lateral decubitus, position with the affected side up. Then the nurse should clean the skin site and surrounding area with an antiseptic solution, such as povidone-iodine, before the health care provider numbs the site and collects the specimen. When the procedure is finished, the nurse should apply ice to the biopsy site to reduce pain.
A client with granulocytopenia has many visitors. What is the most important thing the nurse should tell the visitors to do to prevent infection? Wash their hands. Avoid kissing the client. Leave the children at home. Visit only if they do not have a cold.
Wash their hands. Explanation: Washing hands before, during, and after care has a significant effect on reducing infections. It is advisable to avoid introducing a cold or children's germs and to avoid kissing the client, but the primary prevention technique is handwashing.
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? beta-carotene orange juice milk food
orange juice Explanation: Ascorbic acid (vitamin C) increases iron absorption. Taking iron with a food rich in ascorbic acid, such as orange juice, increases absorption. Milk delays iron absorption. It is best to give iron on an empty stomach to increase absorption. Beta-carotene does not affect iron absorption.
To help prevent hip flexion deformities associated with rheumatoid arthritis, the nurse should help the client assume which position in bed several times a day? very low Fowler's modified Trendelenburg prone side-lying
prone Explanation: To help prevent flexion deformities, a client with rheumatoid arthritis should lie in a prone position in bed for about ½ hour several times a day. This positioning helps keep the hips and knees in an extended position and prevents joint flexion. Low Fowler's, modified Trendelenburg, and side-lying positions do not prevent hip flexion.
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." "Take piroxicam with a full glass of water." "Decrease the piroxicam dosage." "Space the administration every 4 hours."
"Take piroxicam with food or an antacid." Explanation: Taking piroxicam with food or an antacid decreases the risk of gastrointestinal upset. The client may take the full piroxicam dosage once daily or may divide it in half and take a smaller dose every 12 hours; dosing every 4 hours is not recommended. Taking the medication with water will not reduce gastrointestinal upset as significantly as taking with food will. The client should not adjust the dosage of piroxicam or any medication unless directed to do so by a health care provider.
The nurse is educating a client with systemic lupus erythematosus (SLE) about self-management. For what sign or symptom does the nurse tell the client to seek immediate medical attention? having decreased urine output development of a red facial rash feeling fatigued throughout the day experiencing diffuse joint pain
having decreased urine output Explanation: A serious complication of SLE is lupus nephritis, which presents with proteinuria, hematuria, and kidney dysfunction with a decline in glomerular filtration rate. The prognosis for preserving kidney function is best if the condition is detected and treated early, and the nurse ensures the client knows to seek immediate attention for urinary symptoms. Rash, fatigue, and painful joints are typical with SLE but do not pose an immediate threat to the client's health
The nurse is delegating the care of a client with neutropenia who is in isolation to an unlicensed assistive personnel (UAP). What information should the nurse give the UAP about the care of this client? instructing the client to dispose of tissues used after blowing their nose completing the client's care in a calm, unhurried manner completing all of the client's care for the shift at one time listening and responding to the client's feelings of concern
instructing the client to dispose of tissues used after blowing their nose Explanation: The most common source of infection and microbial colonization in neutropenic clients is their own nonpathogenic normal flora. Attention to personal hygiene (e.g., oral, pulmonary, urinary, and rectal care) is essential. It is important to acknowledge the client's concerns and fears and to provide organized, calm, compassionate care, but it is more important to teach the client how to prevent an infection that could be life-threatening.
The nurse is assessing a client with chronic hepatitis B who is receiving lamivudine. What information about the client is most important to communicate to the health care provider? a temperature of 99°F (37.2°C) orally a 6.6-lb (3-kg) weight gain over 2 days intermittent nausea constant fatigue
a 6.6-lb (3-kg) weight gain over 2 days Explanation: The fluid weight gain is of concern since the drug should be used with caution with impaired renal function. Dosage adjustment may be needed with renal insufficiency since the drug is excreted in the urine. Nausea, minor temperature elevation, and fatigue are symptoms that should be monitored, but they are associated with hepatitis.
A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia? dyspnea, tachycardia, and pallor nights sweats, weight loss, and diarrhea nausea, vomiting, and anorexia itching, rash, and jaundice
dyspnea, tachycardia, and pallor Explanation: Signs of iron deficiency anemia include dyspnea, tachycardia, and pallor, as well as fatigue, listlessness, irritability, and headache. Night sweats, weight loss, and diarrhea may signal acquired immunodeficiency syndrome. Nausea, vomiting, and anorexia may be signs of hepatitis B. Itching, rash, and jaundice may result from an allergic or hemolytic reaction.
A client with acquired immunodeficiency syndrome is receiving zidovudine. Which laboratory value indicates an adverse reaction to zidovudine? fasting blood glucose of 104 mg/dl (5.8 mmol/L) platelet count of 240,000/mm3 serum calcium level of 8.9 mg/dl (2.2 mmol/L) red blood cell (RBC) count of 1.8 million/μl (1.8 million x 10 to the 12th/L)
red blood cell (RBC) count of 1.8 million/μl (1.8 million x 10 to the 12th/L) Explanation: Because anemia (characterized by a decrease in RBCs below 4.0 million/μl) (4.0 million x 10 to the 12th/L) is a major adverse effect of zidovudine, the nurse should monitor the client's RBC count and assess for signs and symptoms of decreased cellular oxygenation. Zidovudine doesn't affect the blood glucose level, serum calcium level, or platelet count and the values listed are within normal limits.
A client with multiple sclerosis is taking baclofen. Which sign indicates the drug is having the intended outcome? no longer has double vision increased energy absence of a urinary tract infection obtains relief from muscle spasms
obtains relief from muscle spasms Explanation: Baclofen is a central-acting skeletal muscle relaxant that is used to decrease the spasticity experienced by individuals with multiple sclerosis. Baclofen is not an antibiotic. Baclofen does not decrease fatigue. Common side effects are fatigue and weakness. Baclofen does not improve vision.
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? gtts/min
21 Explanation: To administer whole blood at 500 mL/4 hours using tubing that has a drip factor of 10 gtt/mL, the nurse should first convert the 4 hours into minutes and then use the following formula: 500 mL/240 min × 10 gtt/mL = 21 gtts/min.
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. Administer medication following breakfast daily. Sprinkle the contents of the capsule on food. Administer the medication with an antacid to prevent stomach upset.
Contact the health care provider at first signs of an infection. Explanation: Mofetil is an organ rejection medication that diminishes the body's ability to identify and eliminate pathogens (immunosuppressant). Identifying symptoms of infection at an early state is helpful in treating the infection. This medication is administered on an empty stomach. Typically, capsules would not be opened dispensing medication at one time. Antacids may decrease the absorption of the medication.
A client with acute lymphocytic leukemia is receiving vincristine. Prior to infusing the drug, the nurse administers diphenhydramine. What should the nurse tell the client about the purpose of taking diphenhydramine? Diphenhydramine promotes sleep while the vincristine is infusing. Diphenhydramine decreases the incidence of a reaction to the vincristine. Diphenhydramine potentiates the action of the vincristine. Diphenhydramine reduces anxiety associated with the vincristine infusion.
Diphenhydramine decreases the incidence of a reaction to the vincristine. Explanation: Diphenhydramine is an antihistamine. This drug helps reduce the incidence of an allergic response by blocking the release of histamine. Diphenhydramine also possesses anticholinergic effects and can reduce the incidence of nausea and vomiting for clients receiving chemotherapy. Although diphenhydramine may promote sleep, it is not the primary reason for its administration in this instance. Diphenhydramine will not reduce anxiety or potentiate the action of the vincristine.
The nurse is developing the plan of care for a client newly diagnosed with aplastic anemia. Which is a realistic goal for this client? Learn how to administer weekly vitamin B12 injections. Perform activities of daily living without excessive fatigue or dyspnea. Describe self-care behaviors to prevent the transmission to family members. Correctly demonstrate how to take prescribed anticoagulant drug therapy.
Perform activities of daily living without excessive fatigue or dyspnea. Explanation: With aplastic anemia, measures to conserve energy and reduce oxygen requirements are essential. Therefore, an appropriate goal would be to strive to perform activities of daily living without excessive fatigue or dyspnea. The client needs adequate vitamin B12 in the diet. However, vitamin B12 injections usually are not required. Anticoagulants are contraindicated in clients with low platelet counts, which often occur in aplastic anemia. Aplastic anemia is not contagious. Thus, measures to prevent transmission are inappropriate.
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? Constipation Risk for imbalanced nutrition: More than body requirements Ineffective thermoregulation Risk for impaired skin integrity
Risk for impaired skin integrity Explanation: Progressive systemic sclerosis is a connective tissue disease characterized by fibrosis and degenerative changes of the skin, synovial membranes, and digital arteries. Therefore, the nurse is most likely to formulate a nursing diagnosis of Risk for impaired skin integrity. Because clients with the disease are prone to diarrhea from GI tract hypermotility (caused by pathologic changes), Constipation is an unlikely nursing diagnosis. Progressive systemic sclerosis doesn't cause Ineffective thermoregulation. GI hypermotility may lead to malabsorption, and esophageal dysfunction may cause dysphagia; these conditions put the client with the disease at risk for inadequate nutrition, making Risk for imbalanced nutrition: More than body requirements an improbable nursing diagnosis.
A client who is receiving a blood transfusion suddenly experiences chills and a temperature of 101°F (38.3°C). The client also has a headache and appears flushed. Place the nursing actions in the order in which the nurse should perform them to properly respond to this client's situation. All options must be used. Send the blood bag and administration set to the blood bank. Obtain a blood culture from the client. Infuse normal saline to keep the vein open. Stop the blood infusion.
Stop the blood infusion. Infuse normal saline to keep the vein open. Obtain a blood culture from the client. Send the blood bag and administration set to the blood bank. Explanation: The client is experiencing a septic reaction to the blood transfusion. The nurse should first stop the infusion and notify the health care provider and blood bank. The nurse should then use an infusion of normal saline to keep the vein open. The nurse should next obtain a sample of the client's blood for a blood culture. Last, the nurse should send the blood bag and the administration set to the blood bank for culture.
A client is receiving a unit of packed red blood cells. Before the transfusion started, the client's blood pressure was 90/50 mm Hg, pulse rate was 100 bpm, respirations were 20 breaths/min, and temperature was 98°F (36.7°C). Fifteen minutes after the transfusion starts, the client's blood pressure is 92/54 mm Hg, pulse is 100 bpm, respirations are 18 breaths/min, and temperature is 101.4°F (38.6°C). What should the nurse do first? Stop the transfusion. Raise the head of the bed. Offer the client a cool washcloth. Administer acetaminophen.
Stop the transfusion. Explanation: The nurse's first action should be to stop the transfusion because the client is having a transfusion reaction. It is most important that the client not receive any more blood. Other measures may be appropriate after the transfusion has been stopped. The nurse should raise the head of the bed if the client becomes short of breath, but the client's respiration rate is currently still within the normal range. There is no need to administer acetaminophen to treat the client's temperature spike. The nurse can provide a cool washcloth for a headache or fever; however, this is not a priority.
A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client needs further nutritional counseling? The client cooks tomato-based foods in iron pots. The client adds vitamin C to all meals. The client drinks coffee or tea with meals. The client adds dried fruit to cereal and baked goods.
The client drinks coffee or tea with meals. Explanation: Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron. Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a nonheme or nonanimal iron source. Cooking in iron cookware, especially acid-based foods such as tomatoes, adds iron to the diet. Clients are instructed to add a rich supply of vitamin C to every meal because the absorption of iron is increased when foods with vitamin C or ascorbic acid are consumed
A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the health care provider (HCP) immediately? blood pressure of 145/95 mmHg urine output of 20 ml/hour serum potassium level of 4.9 mEq/L temperature of 99.2°F (37.3°C)
urine output of 20 ml/hour Explanation: Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate notification of the HCP. A serum potassium level of 4.9 mEq/L and a temperature of 99.2°F are normal assessment findings. Although the blood pressure is a bit elevated, this is not a reason to notify the HCP. The nurse knows that hypotension rather than hypertension poses a more serious risk for the client because hypoperfusion of the kidney can complicate recovery.
The nurse is teaching a client about possible side effects when taking a diuretic. Which is an early indication that the client's serum potassium level is below normal? diarrhea muscle cramps in the legs tingling in the fingers sticky mucous membranes
muscle cramps in the legs Explanation: An early indication of hypokalemia is muscle weakness in the legs. Potassium is essential for proper neuromuscular impulse transmission. When neuromuscular impulse transmission is impaired, as in hypokalemia, leg muscles become weak and flabby. If hypokalemia progresses, respiratory muscles become involved and the client becomes apneic. Hypokalemia also causes electrocardiogram changes. Diarrhea is common in hyperkalemia. Sticky mucous membranes are common in hypernatremia. Tingling in the fingers and around the mouth occurs in hypocalcemia
The nurse should assess a client for which complications associated with disseminated intravascular coagulation (DIC)? septic shock congestive heart failure renal calculi pulmonary embolism
pulmonary embolism Explanation: Pulmonary embolism is an indication of intravascular clotting due to the fact that platelets have been significantly decreased and there is clotting and bleeding. Low prothrombin levels will also show that there is a delay in clotting, so the person will bleed for a longer time. The other conditions are not associated with DIC.
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 Explanation: The formula to calculate drip rate is: Rate = (Volume to infuse/time to infuse) x drop factor Rate = (1000 mL/8 hr) x 10 gtt/mL = (1000 mL/480 minutes) x 10 gtt//mL = 20.8 gtt/minute. The nurse will round this value to 21 gtt/minute.
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? Encourage the client to prevent respiratory infections by avoiding social situations. Increase fluids to 3000 mL/day to prevent hemoconcentration. Alternate periods of activity with rest to decrease fatigue. Administer prophylactic antibiotics to prevent infection.
Alternate periods of activity with rest to decrease fatigue. Explanation: Activity intolerance is a common problem for clients with aplastic anemia due to decreased hemoglobin. Alternating activity with periods of rest and assisting the client with activities of daily living are appropriate nursing interventions. Antibiotics will not be administered prophylactically. The client should be taught self-care activities to decrease the likelihood of developing an infection. Adequate fluid intake is important, but the client does not need to force fluids. Hemoconcentration is not a problem in aplastic anemia. The client should be taught good handwashing techniques and limit contact with individuals who have respiratory illnesses; however, the client does not have to avoid all social situations.
The nurse is developing a teaching plan for the client with aplastic anemia. Which instruction is most important to include in the plan? Avoid exposure to others with acute infections. Get 8 hours of sleep at night, and take naps during the day. Practice yoga and meditation to decrease stress and anxiety. Eat animal protein and dark green, leafy vegetables every day.
Avoid exposure to others with acute infections. Explanation: Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia. Strict aseptic technique and reverse isolation are important measures to prevent infection. Although diet, reduced stress, and rest are valued in supporting health, the potentially fatal consequence of an acute infection places it as a priority for teaching the client about health maintenance. Animal meat and dark green leafy vegetables, good sources of vitamin B12 and folic acid, should be included in the daily diet. Yoga and meditation are good complementary therapies to reduce stress. Eight hours of rest and naps are good for spacing and pacing activity and rest.
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). Cleanse the incision site with soap and water. Place an absorbent dressing over the incision. Encourage the client to increase their fluid intake.
Notify the health care provider (HCP). Explanation: The findings (WBC count above normal; inflammation and drainage at the incision site; and an elevated temperature) indicate that the client has an infection. The nurse should first notify the HCP. Encouraging fluids will be helpful, but it is not the first action. The nurse should not cleanse the site or place a dressing over the incision until the HCP writes a prescription to do so.
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 4.5-kg (10-lb) weight loss to limit stress on joints cold compresses to joints for 30 minutes to relieve stiffness a warm shower before performing activities of daily living aspirin after activity to decrease inflammation
a warm shower before performing activities of daily living Explanation: Warm showers, baths, or hand soaks can help relieve joint stiffness and allow the client to more comfortably perform activities of daily living. Aspirin or other anti-inflammatory drugs should be taken before activity, not after, to help decrease inflammation and reduce joint pain and inflammation. Although weight loss may decrease stress on joints, pain and stiffness will continue to be a problem. Cold compresses are most effective for relieving joint pain, whereas moist heat is useful for decreasing pain and stiffness. When cold compresses are applied, their use should be limited to 10 to 15 minutes at a time to decrease the risk for tissue damage.
A client with acquired immunodeficiency syndrome is admitted with Pneumocystis jiroveci pneumonia. The client begins to cry and says, "My friends and relatives have stopped visiting and calling." What is the nurse's best response? "Have you tried speaking with them about how you feel?" "That sounds very difficult. How are you coping with this?" "Would you like me to look for a support group you could join?" "Who are your main supports when you are at home?"
"That sounds very difficult. How are you coping with this?" Explanation: The nurse should acknowledge hearing the client's concern and explore it further. Offering unsolicited advice or solutions (speak to the friends and relatives, join a support group) cuts the exploration of the client's feelings short. While the nurse could explore who the client has as supports, this does not facilitate the exploration of the sadness the client currently is expressing.
A 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 B-positive blood to an AB-positive client. O-negative blood to an O-positive client. O-positive blood to an A-positive client. A-positive blood to an A-negative client.
A-positive blood to an A-negative client. Explanation: An acute hemolytic reaction occurs when there is an ABO or Rh incompatibility. For example, giving A blood to a B client would cause a hemolytic reaction. Likewise, giving Rh-positive blood to an Rh-negative client would cause a hemolytic reaction. It's safe to give Rh-negative blood to an Rh-positive client if there is a blood type compatibility. O-negative blood is the universal donor and can be given to all other blood types. AB clients can receive either A or B blood as long as there isn't an Rh incompatibility.
A client with 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? Use a mask, gloves, and a gown when assisting with the procedure. Send the specimen to the laboratory when someone is available to take it. Maintain sterile technique. Ensure that all instruments used are placed in a sealed and labeled container.
Maintain sterile technique. Explanation: The nurse must ensure that sterile technique is used when a biopsy is obtained because the client is at high risk for infection. In most cases, a lymph node biopsy is sent immediately to the laboratory once it is placed in a specific solution in a closed container. It is not necessary to wear a gown and mask when obtaining the specimen. It is not necessary to use special handling procedures for the instruments used.
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? Encourage the client to prevent respiratory infections by avoiding social situations. Administer prophylactic antibiotics to prevent infection. Alternate periods of activity with rest to decrease fatigue. Increase fluids to 3000 mL/day to prevent hemoconcentration.
Alternate periods of activity with rest to decrease fatigue. Explanation: Activity intolerance is a common problem for clients with aplastic anemia due to decreased hemoglobin. Alternating activity with periods of rest and assisting the client with activities of daily living are appropriate nursing interventions. Antibiotics will not be administered prophylactically. The client should be taught self-care activities to decrease the likelihood of developing an infection. Adequate fluid intake is important, but the client does not need to force fluids. Hemoconcentration is not a problem in aplastic anemia. The client should be taught good handwashing techniques and limit contact with individuals who have respiratory illnesses; however, the client does not have to avoid all social situations.
A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy? "I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal." "I will receive parenteral vitamin B12 therapy monthly for 6 months to a year." "I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear." "I will receive parenteral vitamin B12 therapy for the rest of my life."
"I will receive parenteral vitamin B12 therapy for the rest of my life." 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 is about to undergo bone marrow aspiration of the sternum. What should the nurse tell the client? "After the needle is removed, you will feel a bandage being applied around your chest." "You will not feel the local anesthetic being applied because it will be sprayed on." "You will feel a pulling type of discomfort for a few seconds." "You may feel a solution being wiped over your entire front from your neck down to your navel and out to your shoulders."
"You will feel a pulling type of discomfort for a few seconds." Explanation: As the bone marrow is being aspirated, the client will feel a suction or pulling type of sensation or discomfort that lasts a few seconds. A systemic premedication may be given to decrease this discomfort. A small area over the sternum is cleaned with an antiseptic. It is unnecessary to paint the entire anterior chest. The local anesthetic is injected through the subcutaneous tissue to numb the tissue for the larger-bore needle that is used for aspiration and biopsy. After the needle is removed, pressure is held over the aspiration site for 5 to 10 minutes to achieve hemostasis. A small dressing is applied; a large pressure dressing, such as an Ace bandage, would restrict the expansion of the lungs and is not used
Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. What vital sign values most support the nurse's analysis? Blood pressure of 80/40 mm Hg and pulse of 50 beats per minute. Blood pressure of 150/100 mm Hg and pulse of 130 beats per minute. Blood pressure of 150/100 mm Hg and pulse of 50 beats per minute. Blood pressure of 80/40 mm Hg and pulse of 130 beats per minute.
Blood pressure of 80/40 mm Hg and pulse of 130 beats per minute. Explanation: The client had blood loss during the splenectomy and developed subsequent anemia. With a subnormal Hb level and vertigo when getting out of bed, the nurse is accurate in suspecting orthostasis. Orthostatic changes develop from hypovolemia and cause a drop in blood pressure (evidenced by a blood pressure of 80/40 mm Hg) and a compensatory rise in the heart rate (evidenced by a pulse of 130 beats per minute) when the client rises from a lying position.
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. Iron supplements are contraindicated with folic acid supplementation. It will take several months to notice an improvement. Folic acid should be taken on an empty stomach.
Oral contraceptive use, pregnancy, and lactation increase daily requirements. Explanation: Oral contraceptive use, pregnancy, and lactation are situations that increase demand for folic acid. With supplementation, a response should cause the reticulocyte count to increase within 2 to 3 days after therapy has begun. It is not necessary to take folic acid on an empty stomach. A client may safely take both iron and folic acid supplementation.
A client who had a splenectomy is being discharged. What should the nurse teach the client to do? Report early signs of infection. Make an appointment for the staples to be removed. Alternate rest and activity. Refrain from driving a car for 6 weeks.
Report early signs of infection. Explanation: Clients who have had a splenectomy are especially prone to infection. The reduction of immunoglobulin M leaves the client particularly at risk for immunologic deficiency infections. All clients who have had major abdominal surgery usually receive discharge instructions not to drive because the stomach muscles post-surgery are not strong enough for a person to apply the brake hard/quickly. All clients need to pace activity and rest when going home after major surgery. Rest and sleep allow the growth hormone to repair the tissue, and activity allows the energy and strength to build endurance and muscle strength. An appointment is usually made to see the surgeon in the office 1 week after discharge for follow-up and to remove sutures or staples if this has not already been done.
A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client needs further nutritional counseling? The client drinks coffee or tea with meals. The client adds vitamin C to all meals. The client cooks tomato-based foods in iron pots. The client adds dried fruit to cereal and baked goods.
The client drinks coffee or tea with meals. Explanation: Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron. Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a nonheme or nonanimal iron source. Cooking in iron cookware, especially acid-based foods such as tomatoes, adds iron to the diet. Clients are instructed to add a rich supply of vitamin C to every meal because the absorption of iron is increased when foods with vitamin C or ascorbic acid are consumed.
