Your patient has suspected aplastic anemia and has just returned to the unit to be cared for by you after having bone marrow biopsy done to confirm the diagnosis. Which of the following is the MOST appropriate nursing action?

Assess the patient's lower back for bleeding

Apply a heat pack to the biopsy site for comfort

Have the patient remain bedbound and NPO for 4-6 hours

Give aspirin for hip pain

Answer and Explanation

The Correct Answer is A

A.   This is a crucial action following a bone marrow biopsy, as there is a risk of bleeding at the biopsy site. Monitoring for signs of bleeding or hematoma formation is essential to prevent complications, making this a highly appropriate nursing action.
B.   While applying heat may provide comfort, it is generally not recommended immediately after a biopsy because it can increase blood flow to the area and potentially exacerbate bleeding. Thus, this action may not be appropriate right after the procedure.
C.   While some level of rest is important after a procedure, keeping the patient NPO (nothing by mouth) is unnecessary unless there are specific orders due to anesthesia or other considerations. Additionally, remaining bedbound could increase discomfort or risk of complications like deep vein thrombosis (DVT) if not warranted.
D.   Aspirin should be avoided in this scenario because it is an anticoagulant and can increase the risk of bleeding, particularly after a procedure like a bone marrow biopsy. Instead, other pain management strategies that do not affect clotting should be considered.

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Correct Answer is B

Explanation

A. This statement is not typically related to rheumatoid arthritis. RA does not cause low blood sugar directly. While medications or other conditions might affect blood sugar levels, this is not a common symptom or concern specific to RA.
B. Morning stiffness is a hallmark symptom of rheumatoid arthritis. Patients often report increased stiffness and discomfort in their joints upon waking, which can improve with activity throughout the day.
C. While some individuals might gain weight due to reduced physical activity or medication side effects (like corticosteroids), weight loss is also common due to pain and decreased mobility. Thus, this statement is not universally applicable.
D. Abdominal pain is not a primary symptom of RA. However, certain medications used to treat RA, like nonsteroidal anti-inflammatory drugs (NSAIDs), can cause gastrointestinal discomfort, but this is not a direct result of the disease itself.

A. Perform a sputum culture B. Instruct the patient to obtain yearly influenza vaccination C. Administer oxygen therapy D. Administer antibiotics

Correct Answer is C

Explanation

A. While obtaining a sputum culture is important for identifying the causative organism and guiding antibiotic therapy, it is not an immediate priority. Delaying this test briefly for critical interventions (like oxygen administration) is acceptable, as stabilizing the patient's oxygen levels is more urgent.
B. Educating the patient about vaccination is important for long-term health and prevention of future respiratory infections. However, it does not address the current situation and does not provide immediate benefit for the acute episode of pneumonia.
C. The patient has a SpO2 of 91%, which indicates hypoxemia (low oxygen levels in the blood). In pneumonia, adequate oxygenation is crucial to prevent further respiratory distress and potential complications. Administering oxygen therapy will help improve the oxygen saturation and support the patient’s respiratory function, making this the highest priority intervention.
D. While antibiotics are essential for treating bacterial pneumonia, they may take time to exert their effects. In this acute scenario, the immediate need is to ensure the patient is adequately oxygenated. After oxygen is administered, antibiotics can be given promptly.

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Your patient has suspected aplastic anemia and has just returned to the unit to be cared for by you after having bone marrow biopsy done to confirm the diagnosis. Which of the following is the MOST appropriate nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a new diagnosis of rheumatoid arthritis. Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who has pneumonia. Assessment findings include T 100.4 deg F, RR 30, BP 130/76, HR 100, and SpO2 91% on room air. Which of the following is the PRIORITY intervention?

Correct Answer is C

Explanation

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