The nurse is giving discharge instructions to a patient on the medical-surgical unit. Which patient should be taught about the possibility of an overwhelming infection?

Post chemotherapy

Diagnosed with sickle cell anemia

Diagnosed with multiple myeloma

Post-splenectomy patient

Answer and Explanation

The Correct Answer is D

A.   While patients receiving chemotherapy are at risk for infections due to immunosuppression, the risk of overwhelming infection, particularly from encapsulated bacteria, is higher in post-splenectomy patients due to impaired immune function without the spleen.
B.   Patients with sickle cell anemia are at increased risk of infections, particularly from encapsulated bacteria, due to functional asplenia or hyposplenism, but the risk of overwhelming infection is highest in post-splenectomy patients.
C.   Patients with multiple myeloma are immunocompromised and at increased risk of infections, but they do not have the same risk of overwhelming infection as post- splenectomy patients.
D.   Post-splenectomy patients are at highest risk of overwhelming infection due to impaired immune function resulting from the absence of the spleen, which plays a crucial role in immune surveillance and defense against encapsulated bacteria.

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Correct Answer is ["B","E"]

Explanation

A. Auscultating the brachial pulse is not typically used to assess the patency of an arteriovenous fistula.
B. A thrill is a vibration felt over an arteriovenous fistula or graft and indicates proper blood flow. Palpation for thrill is a standard method to assess fistula patency.
C. Blood pressure measurement does not directly assess the patency of an arteriovenous fistula.
D. Auscultating the radial pulse is not typically used to assess the patency of an arteriovenous fistula.
E. A bruit is a swooshing sound heard over an arteriovenous fistula or graft and indicates turbulent blood flow. Auscultating for bruit is another method to assess fistula patency.
F. Palpate the right radial pulse: Palpating the radial pulse is not typically used to assess the patency of an arteriovenous fistula.

A. Drape the biopsy site. B. Observe the patient for bleeding. C. Explain the procedure to the patient's family. D. Administer an analgesic to the patient.

Correct Answer is D

Explanation

A. While draping is essential for maintaining sterility, it's typically done right before the physician performs the biopsy, not as a primary pre-procedure step for the nurse.
B. Monitoring for bleeding is important after the procedure, not necessarily beforehand.
C. Although informing the family can be helpful, the patient's understanding and consent are the top priority. Pain management is crucial for patient comfort and cooperation during the procedure.
D. Administering an analgesic helps reduce the patient's anxiety and discomfort during the bone marrow biopsy, which can be a painful procedure. This improves patient tolerance and allows the physician to perform the procedure more efficiently.

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The nurse is giving discharge instructions to a patient on the medical-surgical unit. Which patient should be taught about the possibility of an overwhelming infection?

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Naxlex Comprehensive Predictor Exams

The nurse is checking the patency of a new right arm arteriovenous fistula. What action does the nurse use to do this? Select all that apply

Correct Answer is ["B","E"]

Explanation

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Correct Answer is D

Explanation

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