the nurse is assessing an older client for any potential hematologic health problems. which assessment finding is the most significant and would be reported to the primary health care provider?

multiple petechiae and large bruises

a nurse is assessing a dark-skinned client for pallor. what nursing assessment is best to assess for pallor in this client?

assess the conjunctiva of the eye

a hospitalized client has a platelet count of 58,000/mm. what action by the nurse is most appropriate?

place the client on safety precautions

a client is having a bone marrow aspiration and biopsy. what action by the nurse takes priority?

ensure that valid consent is in the medical record

what is the nurses priority when caring for a client who just completed a bone marrow aspiration and biopsy?

check the pressure dressing frequently for signs of excessive or active bleeding

a nurse is caring for four clients. after reviewing today's laboratory results, which client would the nurse assess first?

client with a prothrombin time of 28 seconds

a client is having a bone marrow aspiration and biopsy and is extremely anxious. what action by the nurse is the most appropriate?

assess the clients fears and coping mechanism

a client is having radioisotopic imaging scan. what action by the nurse is most important?

teach the client about the procedure

while taking a client history, which factors that place the client at risk for a hematologic health problem will the nurse document?

family hx

excessive alcohol consumption

diet high in vitamin K

an older client asks the nurse why people my age have weaker immune systems than younger people. what responses by the nurse are best?

bone marrow produces fewer blood cells as you age

you have lower levels of plasma proteins in the blood

the nurse is assessing a client experiencing anemia. which laboratory findings will the nurse expect for this client?

decreased RBC, iron, hemoglobin

a nurse works in a gerontology clinic. what age related changes related to the hematologic system will the nurse expect during health assessment?

nail beds may be thickened or discolored

progressive loss or thinning of hair occurs

a nurse caring for a client with sickle cell disease reviews the clients laboratory test results. which finding would the nurse report to the primary health care provider?

creatine 2.9 mg/dL

the nurse is assessing a client in sickle cell disease crisis. what priority client problem will the nurse expect?

pain

a client in sickle cell crisis is dehydrated and in the emergency department. the nurse plans to start an IV. which fluid choice is best?

(hypotonic) 0.45% normal saline

a client presents to the emergency department in sickle cell disease crisis. what intervention by the nurse takes priority?

administer oxygen

a client hospitalized with sickle cell disease crisis frequently asks for opioid pain medications, often shortly after receiving a dose. the nurses on the unit believe that the client is drug seeking. when the client requests pain medication, what action by the nurse is best?

give the client pain medication if it is time for another dose

the nurse is caring for a client experiencing sickle cell disease crisis. which priority action would help prevent infection?

performing frequent handwashing

a nurse in a hematology clinic is working with four clients who have polycythemia vera. which client would the nurse assess first?

client who reports SOB

the nurse is teaching a client who has pernicious anemia about necessary dietary changes. which statement by the client indicates understanding about those changes?

i'll increase animal proteins like fish and meat

an assistive personnel is caring for a client with leukemia and asks why the client is still at risk for infections when the white blood cell count is high. what response by the nurse is correct?

those WBCs are abnormal and don't provide protection

the family of a neutropenic client reports that the client is not acting right. what action by the nurse is the priority?

assess the client for infection

a nurse is caring for a client who is about to receive a bone marrow transplant. to best help the client cope with the long recovery period, what action by the nurse is best?

help the client find things to hope for each day of recovery

a client asks about the process of graft-versus-host disease. what explanation by the nurse is correct?

the donors cells are actually attacking the patients cells

the nurse is caring for a patient with leukemia who has severe fatigue. what action by the client best indicates that an important outcome to manage this problem has been met?

doing activities of daily living using rest periods

a nurse is caring for a young male client with lymphoma who is to begin treatment. what teaching topic is a priority?

sperm banking

a client has been admitted after sustaining a humerus fracture that occurred when picking up the family cat. what test result would the nurse correlate to this condition?

bence-jones protein in urine

a client with multiple myeloma demonstrates worsening bone density on diagnostic scanes. about what drug does the nurse plan to teach this client?

zoledronic acid

a client has a platelet count of 9000. the nurse finds the client confused and mumbling. what nursing action takes priority at this time?

call the rapid response team

a nurse is preparing to administer a blood transfusion. what action is most important?

ensure that informed consent is obtained

a nurse is preparing to administer a blood transfusion. which action is most important?

put on a pair of gloves

a client receiving a blood transfusion develops anxiety and low back pain. after stopping the transfusion, what action by the nurse is most important?

double check the client and blood product identification

a client has thrombocytopenia. what statement indicates that the client understands self-management of this condition?

i usually put ice on bumps or bruises

a nurse is caring for four clients with leukemia. after hand off report, which client would the nurse assess first?

client who had two bloody diarrhea stools this morning

which statement by a client with leukemia indicates a need for further teaching by the nurse?

i will take a daily laxative to prevent constipation

the nurse is assessing a client who has probable lymphoma. what is the most common early assessment finding for clients with this disorder?

enlarged painless lymph nodes

the nurse assesses a clients oral cavity as seen in the photo below (beefy red tongue), what action by the nurse is most appropriate?

teach the client about cobalamin therapy

a nurse working with clients diagnosed with sickle cell disease teaches about self management to prevent exacerbations and sickle cell crisis. what factors should clients be taught to avoid?

dehydration

extreme stress

high altitudes

pregnancy

which risk factors places a client at risk for leukemia?

chemical exposure

ionizing radiation exposure

viral infection

the nurse is assessing a client with chronic leukemia. which laboratory test results is expected for this client?

decreased hematocrit

abnormal WBC count

low platelet count

decreased hemoglobin

the nurse is caring for a client being treated for hodgkin lymphoma. for which side effects of treatment will the nurse assess?

severe nausea/vomiting

low platelet count

skin irritation at radiation site

low RBC count

the nurse is preparing to administer a blood transfusion. which action by the nurse is most appropriate?

take a full set of vitals prior

hang blood using normal saline and filtered tubing

use gloves to start IV and handle blood

which statements about blood transfusion compatibilities is correct?

donor blood type A can donate to blood type AB

donor blood type O can donate to anyone

the nurse is caring for a client receiving a unit of whole blood. which nursing action is appropriate regarding infusion administration.

use a dedicated filtered blood administration set

stay with the client for the first 15 to 20 minutes

infuse the transfusion with intravenous normal saline

monitor and document vital signs per agency policy

a nurse is preparing to administer a packed red blood cell transfusion to an older adult. understanding age related changes, what alterations in the usual protocol is necessary for the nurse to implement?

assess vital signs at least every 15 minutes

avoid giving other IV fluids

assess the client for fluid overload

which assessment findings may indicate that a client may be experiencing a blood transfusion reaction?

tachycardia

fever

bronchospasm

tachypnea

urticaria

hypotension

a client has received a bone marrow transplant and is waiting for engraftment. what actions by the nurse are most appropriate?

placing the client in protective precautions

teaching visitors appropriate hand hygiene

telling visitors not to bring live flowers or plants

a nurse is caring for an older adult receiving multiple packed red blood cell transfusions. which assessment findings indicate possible transfusion circulatory overload?

acute confusion

dyspnea

HTN

bounding pulse

the nurse teaches an 80 year old client with diminished peripheral sensation. which statement would the nure include in this clients teaching?

look at the placement of your feet when walking

the nurse assesses a clients recent memory. which statement by the client confirms that recent memory is intact?

I ate oatmeal with a wheat toast and orange juice for breakfast

a client is admitted to the emergency department with a probable traumatic brain injury. which assessment finding would be the priority for the nurse to report to the primary health care provider?

decreasing level of consciousness

a nurse asks a client to take deep breaths during an electroencephalography. the client asks "why are you asking me to do this" how would the nurse respond?

hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity

a nurse assesses a client recovering from a cerebral angiography via the right femoral artery. which assessment would the nurse complete?

palpate bilateral lower extremity pulses

when assessing a client who had a traumatic brain injury, the nurse notes that the client is drowsy but easily aroused. what level of consciousness will the nurse document to describe this clients current level of consciousness?

lethargic

the nurse is assessing a client diagnosed with trigeminal nerualgia affecting the cranial nerve V. what assessment findings will the nurse expect for this client?

severe facial pain

the nurse is performing an assessment of cranial nerve 3. which testing is appropriate?

pupil constriction

a nurse cares for a client who is experiencing deteriorating neurologic functions. the client states, "I am worried I will not be able to care for my young children" how would the nurse respond?

can you tell me more about what worries you, so we can see if we can do something to make adjustements

a nurse plans care for a 77 year old client who is experiencing age related peripheral sensory perception changes. which interventions would the nurse include in this clients plan of care?

ensure that the path to the bathroom is free from clutter

after teaching a patient who is scheduled for MRI, the nurse assesses the clients understanding. which statement indicates client understanding of the teaching?

i can return to my usual activities immediately after the MRI

a nurse performs an assessment of pain discrimination on an older adult. the client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. which action would the nurse take next?

touch the pin on the same area of the left hand

a nurse is teaching a client with cerebellar function impairment. which statement would the nurse include in this clients discharge teaching?

ask a friend to drive you to your follow up appointments

which statement would the nurse include when teaching the assistive personnel about how to care for a client with cranial nerve 2 impairment?

tell the client where food items are on the breakfast tray

a nurse prepares a client for LP, which assessment finding would alert the nurse to contact the primary health care provider?

shingles infection on the clients back

a nurse assesses a patient who is recovering from a LP, which complication of this procedure would alert the nurse to urgently contact the PCP?

nausea, vomiting, photophobia, change in LOC, severe headache

the nurse is teaching the daughter of a client who has middle stage alzheimer disease. the daughter asks "will the sertraline my mother is taking improve her dementia" how would the nurse respond about the purpose of the drug?

it will not improve her dementia but can help control emotional responses

a client with early stage alzheimer disease is admitted to the hospital with chest pain. which nursing action is most appropriate to manage this clients dementia?

ensure a structured and consistent environment

the nurse observes a client with late stage alzheimer disease eat breakfast. afterward the client states "I am hungry and want breakfast" what is the nurses best response?

i see you are still hungry. i will get you some toast

the nurse cares for a client with middle stage alzheimer disease. the clients caregiver states "she is always wandering off. what can i do to manage this restless behavior?" what is the nurses best response?

engage the client in scheduled activities throughout the day

the nurse prepares to discharge a client with early to moderate AD. which statement to maintain client safety would the nurse include in the discharge teaching for the caregiver?

install safety locks on all outside doors

the nurse is teaching a family caregiver about how best to communicate with the client who has been diagnosed with AD. which statement by the caregiver indicates a need for further teaching?

i will avoid communicating with the client to prevent agitation

the nurse teaches assistive personnel about how to care for a client with early stage AD. which statement would the nurse include?

reorient the client to the day, time, and environment with each contact

the PCP prescribe donepezil for a client diagnosed with early stage AD. what teaching about this drug will the nurse provide for the clients family caregiver?

report any client dizziness or falls because the drug can cause bradycardia

after teaching the wife of a client who has PD, the nurse assesses the wifes understanding. which statement by the clients wife indicates that she correctly understands changes associated with this disease?

he may have trouble chewing, so I will offer bite sized portions

the nurse plans care for a client with PD. which intervention would the nurse include in this clients plan of care?

keep the head of the bed at 30 degrees or greater

a nurse teaches assistive personnel about how to care for a client with PD, which statement would the nurse include as part of this teaching?

allow the client to be as independent as possible with activities

a client diagnosed with PD will be starting ropinirole for sx control. which statement by the client indicates a need for further teaching?

i know the drug will probably may help me prevent constipation

a nurse is teaching a client who experiences migraine headaches and is prescribed propranolol. which statement would the nurse include in this clients teaching?

take this drug as prescribed even when feeling well, to prevent vascular changes associated with migraine headaches

the nurse assesses a client who has a history of migraines. which sx would the nurse identify as an early sign of a migraine with aura?

visual disturbances

the nurse obtains a health history on a client prior to administering prescribed sumatriptan for migraine headaches. which condition would alert the nurse to withhold the medication and contact the primary health care provider?

heart disease

the nurse assesses a client who is experiencing a common migraine without an aura. which assessment findings would the nurse expect?

headache lasting up to 72 hours

unilateral/pulsating headache

pain worsens w. physical activity, photophobia

the nurse assesses a client who has PD. which s/sx would the nurse recognize as a key feature of this disease?

flexed trunk, slow movements, uncontrolled drooling

a nurse teaches the spouse of a client who has AD. which statements should the nurse include in this teaching related to caregiver stress reduction?

establish advanced directives early

set aside time each day to be away from the client

seek respite care periodically for longer periods of time