Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider?

Presence of plethora (excess body fluid)

Calf swelling and pain

Platelet count 450,000/microL

Hematocrit 55%

Answer and Explanation

The Correct Answer is B

A.   Presence of plethora is a common symptom of polycythemia vera and indicates increased blood volume but is not immediately life-threatening.
B.   Calf swelling and pain could indicate a deep vein thrombosis (DVT), which is a serious complication that requires immediate medical attention.
C.   A platelet count of 450,000/microL is elevated but not as critical as the possibility of a DVT.
D.   Hematocrit of 55% is high, which is expected in polycythemia vera, but it is not as immediately critical as the risk of thrombosis suggested by calf swelling and pain.

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Correct Answer is D

Explanation

A. Pain level of "4" on a scale of 0 to 10 indicates mild pain and may not require immediate attention compared to other potential issues.
B. Vital signs within normal range, including temperature and blood pressure, do not indicate an urgent need for assessment.
C. Urinary catheter output of 150 mL in the last 3 hours is within the expected range postoperatively and does not require immediate assessment.
D. Saturated perineal pads suggest excessive bleeding, which could indicate a potential complication such as hemorrhage. Therefore, the nurse should assess this patient first to ensure prompt intervention if necessary.

A. An endometrial biopsy B. Papanicolaou test C. CA 125 D. Transvaginal ultrasound

Correct Answer is B

Explanation

A. An endometrial biopsy. This test is used to diagnose endometrial cancer, not cervical cancer.
B. Papanicolaou test. The Pap test (Papanicolaou test) is the preferred and standard method for detecting cervical cancer by identifying precancerous or cancerous cells on the cervix.
C. CA 125. CA 125 is a tumor marker that is often used in the detection and management of ovarian cancer, not cervical cancer.
D. Transvaginal ultrasound. This imaging test is typically used to evaluate ovarian and endometrial abnormalities but is not the preferred method for detecting cervical cancer.

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Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider?

Nursing Test Bank

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