How should the nurse respond to a client with leukemia who asks why they are anemic despite increased white blood cell production?

Correct Answer: A

Rationale: The correct answer is A because in leukemia, increased white blood cell production crowds out red blood cells in the bone marrow, leading to anemia. The nurse should explain this to the client to address their confusion. Choice B is incorrect because white blood cells indeed contribute to anemia in leukemia. Choice C is unrelated and does not explain the anemia. Choice D is also incorrect as the issue lies in the overcrowding of red blood cells, not the lifespan of cells.

Correct Answer: A

Rationale: The correct answer is A: Give laxative as ordered. In renal failure, constipation is common due to fluid and electrolyte imbalances. Laxatives can help soften stools and promote bowel movements without increasing fluid intake, which is restricted in renal failure. Increasing fluid intake (B) may worsen fluid overload. Raw fruits and vegetables (C) high in potassium and phosphorus can be harmful. Increasing activity (D) may not directly address the constipation issue.

Correct Answer: B

Rationale: The correct answer is B: Prevent abdominal distention. A Salem Sump tube is a type of nasogastric tube used for decompression and drainage of the stomach. It helps prevent abdominal distention by removing air and fluids from the stomach. This is important in preventing complications such as vomiting, aspiration, and bowel obstructions. Choice A is incorrect because the purpose of a Salem Sump tube is not to apply internal pressure to the abdomen to prevent bleeding. Choice C is incorrect because a Salem Sump tube is not used to instill feedings into the stomach but rather to remove contents from the stomach. Choice D is incorrect because a Salem Sump tube is not used to help in the elimination of urine; it is specifically designed for gastric decompression.

Correct Answer: D

Rationale: The correct answer is D: Notify physician. Delay transfusion. Rationale: 1. Fever (temperature of 38.2 C) indicates possible infection or reaction to transfusion. 2. In a post-surgical patient, fever could be a sign of sepsis or transfusion reaction. 3. Delaying transfusion allows for further assessment and investigation by the physician. 4. Proceeding with transfusion without addressing the fever could worsen the patient's condition. Summary: - Choice A is incorrect because fever post-surgery is not normal and requires further evaluation. - Choice B is incorrect as administering anti-histamine does not address the underlying issue of fever. - Choice C is incorrect as giving Acetaminophen without further evaluation of the cause of fever is not appropriate.

Correct Answer: A

Rationale: The correct answer is A: Temperature: 38.1 C. A fever is the most alarming finding as it indicates a potential systemic infection, especially in a client with a central line and redness at the insertion site. Fever can be a sign of sepsis which requires immediate intervention. Choice B: Expiration date is next month is not relevant to the current situation and does not indicate an immediate threat to the client's health. Choice C: Dressing change due today, while important for infection prevention, is not the most alarming finding in this scenario as it can be addressed promptly. Choice D: Tight tubing connections can lead to complications but are not as urgent or life-threatening as a fever in a client with a central line and redness at the site.