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Questions 158

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Question 1 of 5

The nurse is caring for a client with B-thalassemia major. Which therapy is used to treat B-thalassemia major?

Correct Answer: B

Rationale: B-thalassemia major causes severe anemia due to defective hemoglobin synthesis, requiring frequent blood transfusions to maintain hemoglobin levels. IV fluids, oxygen, and iron therapy (which can cause overload) are not primary treatments.

Question 2 of 5

The charge nurse is making assignments for the day. After accepting the assignment to care for a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which initial action should the charge nurse take?

Correct Answer: D

Rationale: The charge nurse should first ask if the nurse has had chickenpox or been vaccinated, as immunity prevents transmission to the immunocompromised leukemia client. If non-immune, the assignment should be changed. Asking about crusting or explaining no risk is incorrect, as varicella is contagious until lesions crust.

Question 3 of 5

The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a full-strength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?

Correct Answer: A

Rationale: Once the feeding tube placement is confirmed in the stomach, aspiration can occur if the client's stomach becomes too full. When suctioning the trachea, if secretions resemble tube feeding, the client has aspirated the feeding.

Question 4 of 5

A nurse should carefully monitor a client for the following side effect of MgSO4:

Correct Answer: D

Rationale: The nurse should provide good distractors because these symptoms indicate that PIH has become more severe and may precede the convulsive or eclamptic phase. This is the opposite side effect of this medication. This is a common side effect of this medication and needs to be monitored and recorded frequently.

Question 5 of 5

When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is:

Correct Answer: A

Rationale:
Stephens-Johnson syndrome is a toxic effect of phenytoin. Folate deficiency is a side effect of phenytoin, but not a toxic effect. Leukopenic aplastic anemia is a toxic effect of carbamazepine (Tegretol). Granulocytosis and nephrosis are toxic effects of trimethadione (Tridione).

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