Immune/ hematology KAPLAN A – Flashcards

Unlock all answers in this set

Unlock answers
question
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
answer
Periods of dizziness and headache Rationale: -dizziness -headache -confusion and decreased mental alertness may occur due to decreased oxygen delivery to the brain
question
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
answer
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
question
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
answer
The client should be informed that he has antibodies to tuberculosis Rationale: redness and induration (hardening) indicate an antibody reaction to the injected antigen
question
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
answer
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
question
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
answer
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
question
The LVN cares for the client who is on neutropenic precautions Which statement by the client indicates need for further instruction by the LVN
answer
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
question
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
answer
You will need to receive the injection monthy for the rest of your life Rationale: monthly vitamin B12 replacement is necessary to prevent complications
question
The LVN cares for the client diagnosed with iron deficiency anemia Which should the LVN include in the plan of care
answer
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
question
The LVN reinforces teaching for the client diagnosed with leukemia Which statement by the client indicates the need for further teaching
answer
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
question
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
answer
Passive acquired Rationale: Passive acquired immunity occurs when antibodies from a source other than the individual are administered
question
The LVN reinforces teaching for the client who is to take daily oral iron replacement Which instruction should the LVN include
answer
If you take the pills with orange juice, they will be better absorbed Rationale: Vitamin C increases the absorption of iron salts
question
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
answer
Facial swelling and urticarial Rationale: See with type I hypersensitivity reaction and anaphylactic reaction; immediate interventions needed
question
The LVN reinforces teaching for the client who is diagnosed with HIV infection Which statement by the client indicates understanding of the teaching
answer
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
question
The LVN identifies the most common sensory alteration seen in clients diagnosed with multiple sclerosis (MS)
answer
Double vision and blurred vision Rationale: visual changes common manifestation due to inflammation of optic nerve or connections
question
Which would the LVN most likely observe while caring for the client who has systemic lupus erythematosus (SLE)
answer
Joint swelling and tenderness Rationale: clinical manifestations due to arthralgias and arthtirisare most common clinical manifestations of SLE
Get an explanation on any task
Get unstuck with the help of our AI assistant in seconds
New