Immune/ hematology KAPLAN A – Flashcards
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The LVN cares for an 88 year old client with a serum hemoglobin of 8 gm/dL Which should the LVN expect the client to report
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Periods of dizziness and headache Rationale: -dizziness -headache -confusion and decreased mental alertness may occur due to decreased oxygen delivery to the brain
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The LVN observes the nursing assistive person during the care of the client with acquired immunodeficiency syndrome (AIDS) Which situation requires an intervention by the LVN
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While rinsing out the clients urinal, urine splashes in the UAP's eyes Rationale: At risk for exposure to virus; mask and googles are worn during procedures that are likely to generate splashes
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The client who had a purified protein derivative (PPD/ Mantoux) test for tuberculosis screening comes to the clinic for evaluation The LVN notes that the client has a 17 mm reddened area that is firm to the touch at the area of he PPD injection Which best describes the significance of this finding
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The client should be informed that he has antibodies to tuberculosis Rationale: redness and induration (hardening) indicate an antibody reaction to the injected antigen
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The LVN observes that the child at a picnic has been stung on the face by a bee The child says "I am having trouble breathing" The LVN notes urticarial on the child's face and neck and the swelling of the lips Which is the priority action for the LVN to take at this time
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Check the tongue for swelling and listen for stridor Rationale: Bee strings of the faces and neck increase the risk of anaphylactic reaction; assessment of ABC's is priority
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The LVN cares for the client after a bone marrow aspiration and biopsy. Which should the LVN included in the care of the aspiration site
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Apply firm pressure to the aspiration site for several minutes after the procedure Rationale: necessary to apply firm pressure for several minutes to prevent bleeding; if the client has increased bleeding tendencies, pressure might need to be applied longer
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The LVN cares for the client who is on neutropenic precautions Which statement by the client indicates need for further instruction by the LVN
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My family will need to wear gown, gloves and masks when they visit me Rationale: Visitors should be limited to healthy adults; transmission based on precautions not necessary
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The LVN cares for the client receiving Vitamin B12 injection for the treatment of vitamin B12 deficiency When reinforcing teaching, the LVN should include which statement
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You will need to receive the injection monthy for the rest of your life Rationale: monthly vitamin B12 replacement is necessary to prevent complications
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The LVN cares for the client diagnosed with iron deficiency anemia Which should the LVN include in the plan of care
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Reinforce teaching about a diet that contains red meat and green leafy vegetables Rationale: Red and organ meats, egg yolks, and green leafy vegetables have high iron content
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The LVN reinforces teaching for the client diagnosed with leukemia Which statement by the client indicates the need for further teaching
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I need to eat more fruits and veggies to keep my energy level up Rationale: fresh fruits and veggies may contain bacteria or other pathogens
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The LVN administers hepatitis B gamma globulin to the client who was exposed to hepatitis B Which describes the type of immunity that is provided by the hepatitis B gamma globulin
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Passive acquired Rationale: Passive acquired immunity occurs when antibodies from a source other than the individual are administered
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The LVN reinforces teaching for the client who is to take daily oral iron replacement Which instruction should the LVN include
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If you take the pills with orange juice, they will be better absorbed Rationale: Vitamin C increases the absorption of iron salts
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The LVN assists with the care of the client who has a history of allergy to latex. Which clinical manifestation should the LVN immediately report to the RN
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Facial swelling and urticarial Rationale: See with type I hypersensitivity reaction and anaphylactic reaction; immediate interventions needed
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The LVN reinforces teaching for the client who is diagnosed with HIV infection Which statement by the client indicates understanding of the teaching
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It is possible for me to transmit the virus to others at all stages of the disease Rationale: HIV can be transmitted during all stages of the disease; the higher the viral load, the greater the risk of transmission through sexual or perinatal transmission
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The LVN identifies the most common sensory alteration seen in clients diagnosed with multiple sclerosis (MS)
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Double vision and blurred vision Rationale: visual changes common manifestation due to inflammation of optic nerve or connections
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Which would the LVN most likely observe while caring for the client who has systemic lupus erythematosus (SLE)
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Joint swelling and tenderness Rationale: clinical manifestations due to arthralgias and arthtirisare most common clinical manifestations of SLE
