The nurse is assessing an older client for any potential hematologic health problem 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/mm3 what action by the nurse is appropriate

Place client on safety precautions

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

Ensure 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 todays laboratory results which client would the nurse assess first

A client with a prothrombin time (PT) 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 fear and coping mechanisms

A client is having a radioisotopic imaging scan what action by the nurse is the 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 with the nurse document (SATA)

Family history of bleeding gums

Diet low in iron and protein

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(SATA)

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 red blood cell count

Decreased serum iron

Decreased hempglobin

A nurse works in a gerontology clinic what age related changes related to 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 is caring for a client with sickle cell disease (SCD) reviews the clients laboratory test results which finding would the nurse report to the primary health care provider

Creatinine 2.9 mg/dL

The nurse is assessing a client in sickle cell disease(SCD) 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

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 is hospitalized with sickle cell disease crisis frequently asks for opioid pain medications often shortly after receiving dose the nurse 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

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

Client who reports shortness of breath

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 protiens like fish and meat

An assistive personnel is caring for a client with leukemia and asks why the client is still at risk for infection when the white blood cell count(WBC) is high what ressponse by the nurse is correct

Those WBC's 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 priority

Assess the client for infection

A nurse is caring for a client who is about to recieive 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 findings to hope for each day of recovery

A client aks about the process of graft versus host disease what explanation by the nurse is correct

The donors cell 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 ADLs 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 scans about what drug does the nurse plan to teach this client

Zoledronic Acid

A client has a platelet count of 9000/mm 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 important

Double check the client and product identification

A client has a 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 a probable lymphoma what is the most common early assessment finding for clients with this disorder

Enlarged painless lymph nodes

The nurse assess a clients oral cavity as seen in the photo

Teach the client about cobalamin therapy

A nurse is working clients diagnosed with sickle cell disease (SCD) teaches about self management to prevent exacerbations and sickle cell crises what factors should clients be taught to avoid (SATA)

Dehydration

Extreme stress

High altitudes

Pregnancy

Which risk factors places a client at risk for leukemia (SATA)

Chemical exposure

Ionizing radiation exposure

Viral infections

The nurse is assessing a client with chronic leukemia which laboratory test results are expected for this client (SATA)

Decreased hematocrit

Abnormal white blood cell count

Low platelet count

Decreased hemoglobin

The nurse is caring for a client being treated for Hodgkin lymphoma for which side effect of treatment will the nurse assess (SATA)

Severe nausea and vomiting

Low platelet count

Skin irritation at radiation site

Low red blood cell count

The nurse is preparing to administer a blood transfusion which actions by the nurse is most appropriate (SATA)

Hang the blood product using normal saline and a filtered tubing set

Take a full set of vital signs prior to starting the blood transfusion

Use gloves to start the clients IV if needed and to handle the blood product

Which statements about blood transfusion compatibilities are correct (SATA)

Donor blood type A can donate to recipient 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 actions is appropriate regarding infusion administration (SATA)

Use dedicated filtered blood administration

Stay with the client for the first 15 to 20 mins of the infusion

Monitor and document vital signs per agency policy

Infuse the transfusion with intravenous normal saline

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 (are) necessary for the nurse to implement (SATA)

Assess vital signs at least every 15 min

Avoid giving other IV fluids

Assess the client for fluid overload

Which asssessment findings may indicate that a client may be experiencing a blood transfusion reaction(SATA)

Tachycardia

fever

bronchospasm

Tachypnea

Urticaria

Hypotension

A client has recieved a bone marrow transplant and is waiting for engraftment what actions by the nurse are most appropriate (SATA)

Placing the client in protective precautions

Teaching visitors appropriate hand hygiene

Telling visitors nt to bring live flowers or plants

A nurse is caring for an older adult receiving multiple packed red blood cell transfusions which assessment findings indicates possible transfusion circulatory overload

Acute confusion

Dyspnea

Hypertension

Bounding pulse

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

Look at the placement of your feet when walking

The nurse assess a clients recent memory which statement by the client confirms that recent memory is intact

I ate oatmeal with wheat toast and orange juice for breakfast

A client is admitted to the emergency department with a probable traumatic rain injury which assessment finding would be the priority for the nurse to report to the healthcare provider

Decreasing level of consciousness

A nurse asks a client to take a deep breaths during an electroencephalography the client asks why are you taking 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 neuralgia affecting 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 III 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 do something to make adjustments

A nurse plans care for a 77 year old client who is experiencing age related peripheral changes which intervention 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 a magnetic resonance imaging (MRI) the nurse assess 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 of an older adult the client correctly identifies with eyes closed a sharp sensation on the right hand when touhed with a pin which action would thenurse take

Touch the pin on the same area of the lefft hand

A nurse is teaching a client with cerebellar function impairment which statement would the nurse include in the clients teacing

Ask a friend to drive you to your follow up appointments

Which statement would the nurse include when teaching the assistive personnel (AP)about how to care for a client with cranial nerve II impairment

Tell the client where food items are on the breakfast tray

A nurse prepares a client for lumbar puncture(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 lumbar puncture (LP) which complication of this procedure would alert the nurse to urgently contact the primary health care provider

Nausea and vomiting

A nurse assesses a client and notes the clients position as indicated in the illustration how would the nurse document this finding

Decorticate posturing

A nurse assesses a client with a brain tumor the client opens his eyes when the nurse calls his name mumbles in response to questions and follows simple commands how would the nurse document this clients assessment using the glascow coma scale shown below

12

A nurse assesses a client with an injury to the medulla which clinical manifestations would the nurse expect to find(SATA)

Decreased respiratory rate

Impaired swallowing

Inability to shrug

Loss of gag reflex

An 84 year old client who is usually alert and oriented experiences an acute cognitive decline which of the following factors would the nurse anticipate as contributing to the neurologic change (SATA)

Infection

Drug toxicity

Hypoxia

A nurse assesses a client with a brain tumor which newly identified assessment findings would alert the nurse to urgently communicate with the primary health care provider(SATA)

Glasgow coma scale score of 8

Decerebrate posturing

Decreasing level of consciousness

A nurse assesses an older client which assessment findings would the nurse identify as normal changes in the nervous system related to aging ( SATA)

Slower processing time

Change in sleep pattern

The nurse is teaching the daughter of a client who has middle stage Alzheimer disease the daughter asks will the setraline 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 Alzheimers 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(moderate) Alzheimers disease the clients caregivers 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 Alzheimers disease which statement to maintain client safety would the nurse include in the discharge teaching for the caregiver

Install safety locks on all outside doors

A nurse is teaching a family caregiver about how best to communicate with the client who has been diagnosed with Alzheimers disease whcih statement by the caregiver indicated a need for further teaching

I will avoid communicating with the client to prevent agitation

The nurse teaches assistive personnel (AP) about how to care for a client with early stage Alzheimers disease which statement would the nurse include

Reorient the client to the day time and environment with each contact

The primary health care provider prescribes donepezil for a client diagnosed with early stage Alzheimer disease 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 Parkinson disease the nurse assesses the wifes understanding which statement by the clients wofe 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 Parkinson disease which intervention would the nurse include in the clients plan of care

Keep the head of the bed at 30 degrees or greater

A nurse teaches assistive personnel (AP) about hoe to care for a client with parkinsons disease which statement would the nurse include as part of this teaching

Allow the client to be independent as possible with activities

A client diagnosed with parkinson disease will be starting ropinrole for symptom control which statement by the client indicates a need for further teaching

I know the drug will probably make help me prevent constipation

A nurse is teaching a client who experienced 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 assess a client who has a history of migraines which symptom 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 succinate for migraine headaches which condition would alert the nurse to withold the medication and contact the primary health care provider

Heart disease

The nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs followed by an immediate loss of consciousness and jerking of all extremities how would the nurse document this type of seizure

Tonic clonic

The nurse witnesses a client begin to experience a tonic clonic seizure and loss of consciousness what action would the nurse take first

Turn the cleints head to the side

A nurse cares for a client who is experiencing status epilepticus which prescribed medication would the nurse anticipate to prepare for administration

Lorazepam

After teaching a client who is diagnosed with new onset epilepsy and precribed phenytoin the nurse assesses the clients understanding which statement by the client indicates a correct understanding of the teaching

Even when my seizures stop I will continue to take this drug

After teaching a client newly diagnosed with epilepsy the nurse assesses the clients understanding which statement by the client indicates a need for additional teaching

If I am nauseated I will not take my epilepsy medication

The nurse is teaching a group of college students about the importance of preventing meningitis which health promotion activity is the most appropriate for preventing this disease

Obtaining the recommended meningitis vaccination and boosters

A nurse obtains a focused health history for a client who is suspected of having bacterial meninigitis which question would the nurse ask

do you live in a crowded residence

The nurse plans for a client with epilepsy who is admitted to the hospital which interventions would the nurse include in this clients plan of care(SATA)

Have suction equipment with an airway at the bedside

Have oxygen administration set at bedside

Ensure that the client has IV access

The nurse assesses a client who is experiencing a common migraine without an aura which assessment findings would the nurse expect(SATA)

Headache lasting up to 72 hours

Unilateral and pulsating headache

Pain worsens with physical activities

Photophobia

A nurse prepares to provide perineal care to a client with meningococcal meningitis which personal protective equipment would the nurse wear(SATA)

Surgical mask

Gloves

The nurse assesses clients on a medical surgical unit which clients would the nurse identify as at risk for secondary seizures(SATA)

A 26 yr old woman with a left temporal brain tumor

A 38 yr old male client in an alcohol withdrawal program

A 42 yr old football player with traumatic brain injury

A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device for which signs and symptoms would the nurse assess as common complications of this procedure(SATA)

Hoarseness

Dysphagia

The nurse assesses a client who has meningitis which signs and symptoms would the nurse anticipate (SATA)

Photophobia

Decreased level of consciousness

Severe headache

Fever and chills

The nurse assesses a client who has parkinson disease which signs and symptoms would the nurse recognize as a key feature of this disease (SATA)

Flexed trunk

Slow movements

Uncontrolled drooling

A nurse teaches the spouse of a client who has Alzheimer disease which statements should the nurse include in this teaching related to caregiver stress reduction (SATA)

Establish advanced directives early

Set aside time each day to be away from the client

Use discipline to correct inappropriate behaviors

The nurse is caring for a client who has Alzheimer disease the clients wife states I am having trouble managing his behaviors at home which questions would the nurse ask to assess potential causes of the clients behavior problems(SATA)

Does your husband bathe and dress himself independently

Does his behavior become worse around large crowds

Do you have a clock and calendar in the bedroom and kitchen

The nurse is caring for a client in late stage Alzheimer disease which assessment findings will the nurse anticpate (SATA)

Immobile

ADL dependent

Incontinent

Possible seizures

The nurse is preparing to teach a client recently diagnosed with multiple sclerosis about taking glatiramer acetate which statement by the client indicates a need for further teaching

I should report any flulike symptoms to my primary health care provider

A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod for which common side effect would the nurse monitor

Facial flushing

A client who has multiple sclerosis reports increased severe muscle spasticity and tremors what nursing action is most appropriate to manage this clients concern

Request a prescription for an antispasmodic drug as baclofen

A client with multiple sclerosis is being discharged from rehabilitation which statement would the nurse include in the clients dicharge teaching

Avoid overexertion stress and extreme temperature if possible

A nurse assesses a client with spinal cord injury at level T5 the clients blood pressure is 184/95 mmHg and the client presents with a flushed face and blurred vision after raising the head of the bed what action would the nurse take

Palpate the bladder for distension

The nurse initiates care for a client with a cervical cord injury who arrives via emergency medical services what action would the nurse take first

Evaluate respiratory status

A client who had a complete spinal cord injury at level L5-S1 is admitted with a sacral pressure injury what other assessment finding will the nurse anticipate for this client

Flaccid bowel

The nurse is collaborating with the occupational therapist to assist a client with a complete cervical spine cord injury to transfer from the bed to the wheelchair what ambulatory aid would be most appropriate for the client to meet this outcome

Sliding board

The nurse is caring for a 60 year old female client who sustained a thoracic spinal cord injury 10 years ago for which potential complication will the nurse assess during this clients care

fracture

A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program the client states I dont understand the need for rehabilitation the paralysis will not go away and it will not get better how would the nurse respond

The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability

A nurse cares for a client with a spinal cord injury with which interprofessional health team member would the nurse collaborate to assist the client with activities of daily living

Occupational therapist

After teaching a client with a high thoracic spinal cord injury the nurse assess the clients understanding which statement by the client indicates a correct understanding of how to prevent respiratory problems at home

Ill use my incentive spirometer every 2 hours while im awake

A client continues to have persistent low back pain even after using a number of nonpharmacologic pain management strategies which prescribed drug would the nurse anticipate that the client might need to manage the pain

Tramadol

A client is scheduled for a percutaneous endoscopic lumbar discectomy which statement by the client indicates a need for further teaching

Ill be in the hospital for 2 to 3 days

A nurse assesses clients at a community center which client is at greatest risk for low back pain

A 65 year old female with osteoarthritis

A nurse teaches a client who is recovering from an open traditional cervical spinal fusion which statement would the nurse include in this clients potoperative instructions

Wear your neck brace whenever tou are out of bed

A nurse assesses a client who is recovering from an open anterior cervical discectomy and fusion which complication would alert the nurse to urgently communicate with the primary health care provider

Auscultated stridor

A nurse assesses the health history of a client who is prescribed ziconotide for chromic low back pain which assessment question would the nurse ask

have you been diagnosed with a mental health problem

A nurse promotes the prevention of lower back pain by teaching at a community center which statements would the nurse include in this education (SATA)

Participate in an exercise program to strengthen back muscles

wear flat instead of high heeled shoes to work each day

avoid prolonged standing or sitting including driving

A nurse assesses a client who recently experienced a traumatic spinal cord injury which assessment data would the nurse obtain to assess the clients coping strategies (SATA)

Spiritual beliefs

family support

level of independence

previous coping strategies

After teaching a male client with a spinal cord injury at the T4 level the nurse assesses that his understanding which client statements indicate a correct understanding of the teaching related to sexual effects of his injury(SATA)

Ejaculation may not be as predicatable as before

I may urinate with ejaculation but this will not cause infection

I should be able to have an erection with stimulation

A nurse assesses a client who is recovering from an open traditonal lumbar laminectomy with fusion which complications would the nurse report to the primary health care provider (SATA)

Incisional bulging

Clear drainage on the dressing

Sudden severe headache

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the clients hips and sacrum what actions would the nurse take (SATA)

Reposition the client off the reddened areas

Apply a pressure reducing mattress

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago which assessment findings would the nurse correlate neurogenic shock (SATA)

Heart rate of 34 beats/min

Urine output less than 30 mL/hr

Decreased level of conscioussness

A nurse plans care for a client with a halo fixator which interventions would the nurse include in this clients plan of care (SATA)

Assess the pin sites for signs of infection

Assess the chest and back for skin breakdown

A nurse assesses a client who is recovering from an open traditonal anterior cervical fusion which assessment findings would alert the nursing to a complication from this procedure (SATA)

Difficulty swallowing

Hoarse voice

A nurse assesses cerebrospinal fluid leaking onto a clients surgical dressing what actions would the nurse take(SATA)

Place the client in a flat position

Report the leak to the surgeon

The nurse is taking a history on an older adult which factors would the nurse assess as potential risks (SATA)

Scoliosis

Spinal stenosis

Hypocalcemia

Osteoporosis

osteoarthritis