Which nursing intervention(s) should be employed when caring for the bone marrow donor immediately following a bone marrow aspiration? (SELECT ALL THAT APPLY)
Administer aspirin for bone pain
Place the client in high Fowler's position
Apply direct pressure to the puncture site
Assess and document vital signs
Initiate neutropenic precautions
Correct Answer : C,D
A. Aspirin can increase the risk of bleeding and is typically contraindicated in patients who have undergone procedures like bone marrow aspiration. Instead, acetaminophen may be recommended for pain relief, as it does not have blood-thinning effects.
B. After a bone marrow aspiration, the donor is typically advised to lie flat or in a comfortable position to minimize discomfort and reduce the risk of bleeding. High Fowler's position may not provide the necessary comfort or support needed post-procedure.
C. Applying direct pressure to the puncture site is a critical intervention to minimize bleeding and promote clotting at the site of the aspiration. The nurse should apply pressure for a sufficient amount of time as per protocol.
D. Monitoring vital signs is important after any invasive procedure to detect any complications early, such as bleeding or signs of shock. Documenting vital signs also ensures continuity of care.
E. This choice is not applicable immediately after bone marrow aspiration for a donor. Neutropenic precautions are typically implemented for patients who have low white blood cell counts due to chemotherapy or other conditions. Bone marrow donors do not require these precautions immediately after donation unless there is a specific concern for infection or a significant drop in white blood cell counts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A calcaneal spur, or heel spur, is a bony growth on the heel bone. This condition is primarily related to foot pain and does not have a direct link to the risk of stroke. It is not relevant in assessing stroke risk.
B. This elevated blood pressure reading indicates hypertension, which is a significant risk factor for both ischemic and hemorrhagic strokes. Chronic high blood pressure can lead to damage of the blood vessels, making them more susceptible to rupture, thus increasing the risk of a hemorrhagic stroke.
C. A glycosylated hemoglobin (HbA1c) level of 5.9% indicates well-managed diabetes, typically within the normal range for most individuals. While uncontrolled diabetes is a risk factor for vascular disease, this level suggests adequate control and does not specifically indicate an increased risk for a hemorrhagic stroke.
D. A recent endoscopy itself does not indicate a direct risk for a hemorrhagic stroke. However, if the endoscopy was performed due to gastrointestinal bleeding or if it resulted in complications, there could be indirect implications, but this option alone does not signify an increased risk for hemorrhagic stroke.
Correct Answer is A
Explanation
A. This response is relevant and helps assess the characteristics of the lump. Pain can be an important factor in differentiating between conditions, such as epididymitis, testicular torsion, or tumors. However, while it is a useful question, it may not provide a comprehensive assessment of the situation.
B. This question can be relevant depending on the underlying cause of the lump. Issues with urination may suggest a problem related to the prostate or bladder rather than the testicle itself. While it can help assess urinary tract involvement, it may not directly address the significance of the lump in the testicle.
C. This question is important in the context of sexually transmitted infections (STIs), which can cause scrotal swelling or lumps due to conditions like epididymitis or orchitis. However, it does not directly assess the lump itself, making it less focused on the immediate concern.
D. This question addresses the possibility of an STI and related conditions. While it is relevant, it is not the best immediate question concerning the lump in the testicle. The presence of discharge may not directly correlate with the testicular lump itself.
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