NCLEX 3500: Hematological and Immune Disorders Exam Questions And Answers 100% Verified

NCLEX 3500: Hematological and Immune Disorders Exam Questions And Answers 100% Verified Which nursing diagnosis should the nurse expect to see in a care plan for a client in sickle cell crisis? 1. Imbalanced nutrition: Less than body requirements related to poor intake 2. Disturbed sleep pattern related to external stimuli 3. Impaired skin integrity related to pruritus 4. Acute pain related to sickle cell crisis - answerAnswer: 4 RATIONALES: In sickle cell crisis, sickle-shaped red blood cells clump together in a blood vessel, which causes occlusion, ischemia, and extreme pain. Therefore, option 4 is the appropriate choice. Although nutrition is important, poor nutritional intake isn't necessarily related to sickle cell crisis. During sickle cell crisis, pain or another internal stimulus is more likely to disturb the client's sleep than external stimuli. Although clients with sickle cell anemia can develop chronic leg ulcers caused by small vessel blockage, they don't typically experience pruritus. A 33-year-old client who tested positive for human immunodeficiency virus (HIV) and has pancreatitis is admitted to the medical unit. The nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director about reading the client's chart. The director states that the client is her neighbor's son. What action should the nurse take to protect the client's right to privacy? 1. Inform the nurse director she's violating the client's right to privacy and ask her to return the chart. 2. Remind the nurse director not to share the client's medical information with anyone because of his HIV status. 3. Report the incident to the medical director. 4. Ask the nurse director if she has permission to read the client 's chart, and if she does not, tell her she needs to obtain it before further reading. - answerAnswer 1: RATIONALES: Under the Health Insurance Portability and Accountability Act (HIPAA), personal health information may not be used for purposes not related to health care. The nurse director found reading the chart isn't providing health care to the client and, therefore, doesn't require access to the chart. The nurse should confront the nurse director and ask her to return the client's chart. The director shouldn't have access to this client's healthcare information regardless of his HIV status. If she doesn't comply with the nurse's request, the nurse should report the incident to her nurse manager, so the infraction can be reported through the proper channels. The staff nurse shouldn't report the incident to the medical director. Option 4 doesn't protect client confidentiality. A client with rheumatoid arthritis is being discharged with a prescription for aspirin (Ecotrin), 600 mg P.O. every 6 hours. The nurse should instruct the client to notify the physician if which adverse drug reaction occurs? 1. Dysuria 2. Tinnitus 3. Leg cramps 4. Constipation - answerAnswer 2: RATIONALES: 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). The other options aren't associated with aspirin use or toxicity. A client with acquired immunodeficiency syndrome (AIDS) is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do? 1. Continue with the bath and tell the client not to worry. 2. Ask the physician to obtain a psychiatric consultation. 3. Listen and show interest as the client expresses feelings. 4. State that these friends' behavior shows that they aren't true friends. - answerAnswer: 3 RATIONALES: The nurse should listen actively and nonjudgmentally as the client expresses feelings. Telling the client not to worry would provide false reassurance. A psychiatric consultation would be appropriate only after further assessment. Stating that the client's friends aren't true friends would discount the client's feelings. A client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product? 1. Dextrose 5% in water 2. Dextrose 5% in normal saline solution 3. Lactated Ringer's solution 4. Normal saline solution - answerAnswer 4: RATIONALES: Normal saline solution is used for administering blood transfusions. Lactated Ringer's solution or dextrose solutions may cause blood clotting or RBC hemolysis. Clients with cancer who receive multiple blood transfusions are at risk for forming antibodies against the blood. What precautions should the nurse take when administering blood to a client with a history of multiple transfusions? 1. Use a blood filter to filter the leukocytes. 2. Ask all clients about previous blood product administration. 3. Administer allogeneic blood products. 4. Make sure that leukocyte reduced blood products are prescribed. - answerAnswer 4: RATIONALES: The nurse should make sure that leukocyte reduced blood products are prescribed to reduce the risk of a blood transfusion reaction caused by antibody formation. Filter use doesn't guarantee leukocyte removal. The nurse can ask the client about previous blood transfusions, but that doesn't protect the client from a transfusion reaction. Allogeneic blood products aren't always possible in clients with a history of multiple blood transfusions. A client who is receiving cyclosporine (Sandimmune) must practice good oral hygiene, including regular brushing and flossing of the teeth, to minimize gingival hyperplasia. Good oral hygiene also is essential to minimize gingival hyperplasia during long-term therapy with certain drugs. Which drug falls into this category? 1. procainamide (Pronestyl) 2. azathioprine (Imuran) 3. phenytoin (Dilantin) 4. allopurinol (Zyloprim) - answerAnswer: 3 RATIONALES: Gingival hyperplasia may occur with long-term administration of phenytoin, an anticonvulsant. This adverse effect presumably is dose related. Frequent toothbrushing removes food particles and helps prevent infection; regular dental care and frequent gum massage also are recommended. Gingival hyperplasia isn't a reported adverse effect of procainamide, azathioprine, or allopurinol. The nurse is caring for a client with thrombocytopenia. What is the best way to protect this client? 1. Limit visits by family members. 2. Encourage the client to use a wheelchair. 3. Use the smallest needle possible for injections. 4. Maintain accurate fluid intake and output records. - answerAnswer 3: RATIONALES: Because thrombocytopenia alters coagulation, it poses a high risk of bleeding. To help prevent capillary bleeding, the nurse should use the smallest needle possible when administering injections. The nurse doesn't need to limit visits by family members because they don't pose any danger to the client. The nurse should provide comfort measures and maintain the client on bed rest; activities such as using a wheelchair can cause bleeding. The nurse records fluid intake and output to monitor hydration; however, this action doesn't protect the client from a complication of thrombocytopenia. Which nonpharmacologic interventions should the nurse include in the care plan for a client who has moderate rheumatoid arthritis (RA)? 1. Massaging inflamed joints 2. Avoiding range-of-motion (ROM) exercises 3. Applying splints to inflamed joints 4. Using assistive devices at all times 5. Selecting clothing that has Velcro fasteners 6. Applying moist heat to joints - answerAnswer 3,5,6 RATIONALES: Supportive, nonpharmacologic measures for the client with RA include applying splints to rest inflamed joints, using Velcro fasteners on clothes to aid in dressing, and applying moist heat to joints to relax muscles and relieve pain. Inflamed joints should never be massaged because doing so can aggravate inflammation. A physical therapy program, including ROM exercises and carefully individualized therapeutic exercises, prevents loss of joint function. Assistive devices should be used only when marked loss of ROM occurs. A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing intervention is the most important? 1. Immediately stop the transfusion, infuse dextrose 5% in water (D5W), and call the physician. 2. Slow the transfusion and monitor the client closely. 3. Stop the transfusion, notify the blood bank, and administer antihistamines. 4. Immediately stop the transfusion, infuse normal saline solution, notify the blood bank, and call the physician. - answerAnswer 4: RATIONALES: When a transfusion reaction occurs, the transfusion should be immediately stopped, normal saline solution should be infused to maintain venous access, and the blood bank and physician should be notified immediately. Other nursing actions include saving the blood bag and tubing, rechecking the blood type and identification numbers on the blood tags, monitoring vital signs, obtaining necessary laboratory blood and urine samples, providing proper documentation, and monitoring and treating for shock. Because they can cause red blood cell