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82 notecards = 21 pages (4 cards per page)

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med surg 3 chapter 36,37,38,39

front 1

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?

back 1

multiple petechiae and large bruises

front 2

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

back 2

assess the conjunctiva of the eye

front 3

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

back 3

place the client on safety precautions

front 4

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

back 4

ensure that valid consent is in the medical record

front 5

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

back 5

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

front 6

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

back 6

client with a prothrombin time of 28 seconds

front 7

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

back 7

assess the clients fears and coping mechanism

front 8

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

back 8

teach the client about the procedure

front 9

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

back 9

family hx

excessive alcohol consumption

diet high in vitamin K

front 10

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

back 10

bone marrow produces fewer blood cells as you age

you have lower levels of plasma proteins in the blood

front 11

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

back 11

decreased RBC, iron, hemoglobin

front 12

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

back 12

nail beds may be thickened or discolored

progressive loss or thinning of hair occurs

front 13

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?

back 13

creatine 2.9 mg/dL

front 14

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

back 14

pain

front 15

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?

back 15

(hypotonic) 0.45% normal saline

front 16

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

back 16

administer oxygen

front 17

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?

back 17

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

front 18

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

back 18

performing frequent handwashing

front 19

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

back 19

client who reports SOB

front 20

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

back 20

i'll increase animal proteins like fish and meat

front 21

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?

back 21

those WBCs are abnormal and don't provide protection

front 22

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

back 22

assess the client for infection

front 23

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?

back 23

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

front 24

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

back 24

the donors cells are actually attacking the patients cells

front 25

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?

back 25

doing activities of daily living using rest periods

front 26

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

back 26

sperm banking

front 27

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?

back 27

bence-jones protein in urine

front 28

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

back 28

zoledronic acid

front 29

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

back 29

call the rapid response team

front 30

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

back 30

ensure that informed consent is obtained

front 31

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

back 31

put on a pair of gloves

front 32

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

back 32

double check the client and blood product identification

front 33

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

back 33

i usually put ice on bumps or bruises

front 34

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

back 34

client who had two bloody diarrhea stools this morning

front 35

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

back 35

i will take a daily laxative to prevent constipation

front 36

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

back 36

enlarged painless lymph nodes

front 37

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

back 37

teach the client about cobalamin therapy

front 38

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?

back 38

dehydration

extreme stress

high altitudes

pregnancy

front 39

which risk factors places a client at risk for leukemia?

back 39

chemical exposure

ionizing radiation exposure

viral infection

front 40

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

back 40

decreased hematocrit

abnormal WBC count

low platelet count

decreased hemoglobin

front 41

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

back 41

severe nausea/vomiting

low platelet count

skin irritation at radiation site

low RBC count

front 42

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

back 42

take a full set of vitals prior

hang blood using normal saline and filtered tubing

use gloves to start IV and handle blood

front 43

which statements about blood transfusion compatibilities is correct?

back 43

donor blood type A can donate to blood type AB

donor blood type O can donate to anyone

front 44

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

back 44

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

front 45

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?

back 45

assess vital signs at least every 15 minutes

avoid giving other IV fluids

assess the client for fluid overload

front 46

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

back 46

tachycardia

fever

bronchospasm

tachypnea

urticaria

hypotension

front 47

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

back 47

placing the client in protective precautions

teaching visitors appropriate hand hygiene

telling visitors not to bring live flowers or plants

front 48

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

back 48

acute confusion

dyspnea

HTN

bounding pulse

front 49

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

back 49

look at the placement of your feet when walking

front 50

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

back 50

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

front 51

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?

back 51

decreasing level of consciousness

front 52

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?

back 52

hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity

front 53

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

back 53

palpate bilateral lower extremity pulses

front 54

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?

back 54

lethargic

front 55

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?

back 55

severe facial pain

front 56

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

back 56

pupil constriction

front 57

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?

back 57

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

front 58

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?

back 58

ensure that the path to the bathroom is free from clutter

front 59

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

back 59

i can return to my usual activities immediately after the MRI

front 60

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?

back 60

touch the pin on the same area of the left hand

front 61

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

back 61

ask a friend to drive you to your follow up appointments

front 62

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

back 62

tell the client where food items are on the breakfast tray

front 63

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

back 63

shingles infection on the clients back

front 64

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?

back 64

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

front 65

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?

back 65

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

front 66

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?

back 66

ensure a structured and consistent environment

front 67

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?

back 67

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

front 68

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?

back 68

engage the client in scheduled activities throughout the day

front 69

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?

back 69

install safety locks on all outside doors

front 70

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?

back 70

i will avoid communicating with the client to prevent agitation

front 71

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

back 71

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

front 72

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?

back 72

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

front 73

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?

back 73

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

front 74

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

back 74

keep the head of the bed at 30 degrees or greater

front 75

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?

back 75

allow the client to be as independent as possible with activities

front 76

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

back 76

i know the drug will probably may help me prevent constipation

front 77

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

back 77

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

front 78

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?

back 78

visual disturbances

front 79

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?

back 79

heart disease

front 80

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

back 80

headache lasting up to 72 hours

unilateral/pulsating headache

pain worsens w. physical activity, photophobia

front 81

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

back 81

flexed trunk, slow movements, uncontrolled drooling

front 82

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?

back 82

establish advanced directives early

set aside time each day to be away from the client

seek respite care periodically for longer periods of time