Nursing Elites

1. Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia?

• A. Potential complication: seizures
• B. Potential complication: infection
• C. Potential complication: neurogenic shock
• D. Potential complication: pulmonary edema

Correct answer: B

Rationale: The correct answer is B: Potential complication: infection. Patients with idiopathic aplastic anemia have pancytopenia, which puts them at a high risk for infections due to decreased production of all blood cells (red blood cells, white blood cells, and platelets). Infection is a significant concern in these patients. Choices A, C, and D are incorrect because seizures, neurogenic shock, and pulmonary edema are not typically associated with idiopathic aplastic anemia. While seizures can occur in some conditions that affect the brain, neurogenic shock is related to spinal cord injury, and pulmonary edema is more commonly seen in conditions like heart failure.

2. Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the healthcare provider?

• A. The platelet count is 52,000/µL
• B. The patient is difficult to arouse
• C. There are purpura on the oral mucosa
• D. There are large bruises on the patient's back

Correct answer: B

Rationale: The correct answer is B. Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life-threatening and requires immediate action. While a low platelet count (choice A) is concerning in thrombocytopenia, it does not require immediate communication unless accompanied by active bleeding or other critical symptoms. Purpura on the oral mucosa (choice C) and large bruises on the patient's back (choice D) are important findings in thrombocytopenia but do not indicate an immediate life-threatening situation like a possible cerebral hemorrhage.

3. An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to

• A. provide a diet high in vitamin K
• B. alternate periods of rest and activity
• C. teach the patient how to avoid injury
• D. place the patient on protective isolation

Correct answer: B

Rationale: In severe hemolytic anemia, the priority nursing intervention is to alternate periods of rest and activity. This approach helps to balance activity levels to prevent excessive fatigue while promoting mobility and preventing complications such as muscle weakness or deconditioning. Providing a diet high in vitamin K (choice A) is not directly related to managing hemolytic anemia. Teaching the patient how to avoid injury (choice C) is important but may not be the immediate priority. Placing the patient on protective isolation (choice D) is not indicated for hemolytic anemia, as it is not a contagious condition.

4. An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/µL during chemotherapy is to

• A. check all stools for occult blood
• B. encourage fluids to 3000 mL/day
• C. provide oral hygiene every 2 hours
• D. check the temperature every 4 hours

Correct answer: A

Rationale: The correct answer is to check all stools for occult blood. With a platelet count of 18,000/µL, the patient is at a high risk of spontaneous bleeding. Checking stools for occult blood can help detect any internal bleeding early. Encouraging fluids and providing oral hygiene are important interventions in general, but in this case, monitoring for bleeding takes precedence. Checking the temperature every 4 hours is not directly related to the patient's current condition and platelet count.

5. A healthcare provider reviews the laboratory data for an older patient. The healthcare provider would be most concerned about which finding?

• A. Hematocrit of 35%
• B. Hemoglobin of 11.8 g/dL
• C. Platelet count of 400,000/μL
• D. White blood cell (WBC) count of 2800/μL

Correct answer: D

Rationale: A low white blood cell (WBC) count in an older patient is concerning as it indicates a potential compromise in the patient's immune function. White blood cells are crucial for fighting infections and a low count could lead to an increased risk of infections. Hematocrit, hemoglobin, and platelet count are important parameters to assess, but a low WBC count takes priority in this case due to its direct impact on immune health.

Similar Questions