HESI Med Surg Hematological

Correct Answer: Consent needs to be signed.

Explanation:

Before any diagnostic procedure or test, it is essential that the nurse ensures the client has provided informed consent. This means the client understands the nature of the test, the potential risks, and any other relevant details. The nurse should explain the procedure, allow the client to ask questions, and ensure they voluntarily sign the consent form prior to testing. This step is a legal and ethical requirement for many diagnostic procedures.

Why the Other Options Are Incorrect:

Tasks are necessary to participate in the test.

While some tests may require specific instructions (e.g., fasting or avoiding certain medications), this option is too vague to be considered a primary educational point for the client. The nurse should clarify specific instructions related to the test rather than simply listing "tasks" as a requirement.

Anesthetic will be applied.

Not all diagnostic tests involve anesthesia. Whether an anesthetic is used depends on the procedure being performed. It would be inappropriate for the nurse to make this general statement unless anesthesia is specifically required for the test. The nurse should provide accurate information based on the procedure to be performed.

They will need someone to drive them home.

While this may be important for tests involving sedation or anesthesia, it is not a universal requirement for all diagnostic testing. The nurse should clarify whether the client will need assistance after the procedure based on the specific test.

Summary:

Consent needs to be signed, as obtaining informed consent is a critical step in preparing a client for diagnostic testing. Other options are dependent on the specific procedure and are not general requirements for all tests.

Correct answer: D. Fever and sore throat

Explanation:

Leucopenia refers to a decrease in white blood cells, particularly neutrophils, which play a key role in the body's defense against infection. When a client is leucopenic, their ability to fight infections is impaired, making them more susceptible to bacterial and viral infections. Therefore, fever and sore throat are classic signs of infection and are important indicators that the client might be developing an infection due to their suppressed immune system. Prompt recognition of these signs is critical to prevent severe infections.

Why the Other Options Are Incorrect:

A. Unusual or easy bleeding.

This is more indicative of thrombocytopenia (low platelet count), not leucopenia. Thrombocytopenia increases the risk of bleeding, while leucopenia increases infection risk.

B. Oozing from injection sites.

Similar to option A, this relates more to impaired clotting due to low platelets or coagulation issues rather than leucopenia.

C. Dark, tarry stools.

This typically indicates gastrointestinal bleeding (melena), which is associated with bleeding disorders or gastrointestinal lesions, not with leucopenia.

Summary:

The correct answer is D. Fever and sore throat, because these are hallmark signs of infection that can result from leucopenia due to the client's reduced white blood cell count. The other options are associated with bleeding tendencies, which are not directly related to leucopenia.

Correct Answer: WBCs 32,000/mm³

Explanation:

Leukemia is a group of cancers that affect the blood and bone marrow, typically involving the overproduction of abnormal white blood cells (WBCs). These immature or nonfunctional WBCs crowd out healthy blood cells, disrupting normal hematopoiesis. A WBC count of 32,000/mm³ is significantly elevated (normal range is about 4,500 to 11,000/mm³), and such leukocytosis is commonly seen in leukemia, particularly in its early or active stages.

The elevated WBC count in leukemia often consists of immature or abnormal white cells (blasts) that do not function properly in immune defense. This abnormal increase is a hallmark feature of many forms of leukemia, especially acute types.

Why the Other Options Are Incorrect:

Platelets 300,000/mm³

This is a normal platelet count (normal range: 150,000–400,000/mm³). In leukemia, especially as the disease progresses or during chemotherapy, platelet counts often drop, leading to thrombocytopenia, not a normal value.

Hemoglobin 15 g/dL

This is within the normal range for hemoglobin (approximately 13.5–17.5 g/dL for men and 12–15.5 g/dL for women). In leukemia, hemoglobin is often low due to bone marrow suppression, which leads to anemia.

Blood pH of 7.35

This is the low end of the normal pH range (7.35–7.45). While metabolic changes can occur in leukemia, blood pH usually remains normal unless complicated by infection, tumor lysis syndrome, or respiratory/metabolic imbalances. It is not a primary indicator of leukemia.

Summary:

The most indicative lab value among the options for leukemia is WBCs 32,000/mm³, as elevated white blood cell counts are a hallmark of the disease.

Correct Answer: Safety

Explanation:

Multiple myeloma is a cancer of the plasma cells in the bone marrow, which can lead to bone damage, including bone pain, osteoporosis, and fractures. Clients with multiple myeloma are at an increased risk of pathological fractures (fractures that occur without significant trauma) due to the destruction of bone by the cancer cells. This makes safety the most important nursing priority in preventing fractures during activities like ambulation.

When assisting a client with multiple myeloma to ambulate, it is essential to ensure the environment is safe to prevent falls and injuries. This includes providing supportive devices (such as walkers or canes), making sure the pathway is clear of obstacles, and offering assistance with balance and coordination. By focusing on safety, the nurse can help prevent falls and fractures that are more likely due to weakened bones from the disease.

Why the Other Options Are Incorrect:

A. Increased mobility

While maintaining mobility is important for overall health, especially in clients with multiple myeloma, increased mobility does not specifically address the risk of fractures. The focus should be on safe ambulation rather than just increasing the amount of movement. The client's bones are already compromised due to bone marrow involvement, and the primary concern is preventing fractures during ambulation, not solely increasing mobility.

B. Adequate hydration

Adequate hydration is important for clients with multiple myeloma, particularly to help with kidney function and to reduce the risk of hypercalcemia (which can occur due to bone breakdown). However, hydration does not directly address the risk of fractures from weakened bones. Safety is a more critical focus to prevent injury while ambulating.

D. Adequate nutrition

While adequate nutrition is essential for overall health, particularly for supporting bone health (e.g., calcium and vitamin D for bone strength), the primary concern in preventing fractures during ambulation is ensuring the client's safety during movement. While nutrition plays a role in long-term bone health, safety is more immediate and vital to prevent falls and fractures in the client with multiple myeloma.

Summary:

The most important nursing diagnosis to help prevent fractures in a client with multiple myeloma during ambulation is safety, as the client is at high risk for fractures due to weakened bones. 

Correct Answer: Immunologic agents

Explanation:

Globulins are a group of proteins in the plasma that primarily function as immunologic agents. They include antibodies (also known as immunoglobulins) that play a crucial role in the immune response by identifying and neutralizing foreign substances such as bacteria, viruses, and toxins. Globulins also include other proteins involved in immune responses and transport of lipids and hormones.

Why the Other Options Are Incorrect:

Destruction of invading organisms

While globulins, particularly immunoglobulins, are involved in identifying and neutralizing pathogens, they do not directly destroy invading organisms. The actual destruction of pathogens is carried out by other components of the immune system, such as phagocytes (e.g., neutrophils and macrophages) and the complement system.

Precursors to clot formation

This function is carried out by fibrinogen, not globulins. Fibrinogen is a plasma protein that is converted to fibrin during the blood clotting process, forming a mesh that helps to stop bleeding.

Transport of oxygen to the tissues

The transport of oxygen to tissues is the primary role of erythrocytes (red blood cells) and is facilitated by hemoglobin. Globulins do not play a direct role in oxygen transport.

Summary:

The correct answer is A. Immunologic agents, as globulins primarily function as antibodies and other immune proteins. The other options describe functions of other blood components, such as fibrinogen for clot formation and erythrocytes for oxygen transport.

Correct Answer: A combination of a weak saline and water solution should be used to rinse the mouth before and after each meal

Explanation:

Oral mucositis is a painful inflammation and ulceration of the mucous membranes lining the mouth, commonly caused by radiation therapy to the head and neck or chemotherapy. To promote healing and reduce discomfort, it is essential to maintain gentle, frequent oral hygiene. A weak saline solution (salt water) helps to keep the mouth clean, reduce bacteria, and soothe irritated tissues without being too harsh.

Rinsing before and after meals helps remove food particles, reduces the risk of infection, and can make eating more comfortable. This practice is widely recommended as a core part of mucositis care.

Why the Other Options Are Incorrect:

Oral hygiene should be performed in the morning and evening

While oral hygiene is critical, in cases of mucositis, more frequent and gentle oral care (such as after every meal and at bedtime) is preferred. Limiting it to just morning and evening is inadequate for optimal care.

High-protein foods, such as peanut butter, should be incorporated in the diet

Protein is important for healing, but peanut butter is thick and sticky, which can be difficult and painful to swallow for someone with mucositis. Softer, non-irritating, high-protein options like scrambled eggs or smoothies are better tolerated.

A glass of wine per day will not pose any further harm to the oral cavity

Alcohol is an irritant and can worsen mucosal damage. It also dries out the mucosa and increases discomfort and the risk of infection. It should be avoided entirely during mucositis.

Summary:

The most appropriate and evidence-based home care measure for oral mucositis is a combination of a weak saline and water solution should be used to rinse the mouth before and after each meal, as it helps maintain oral hygiene and promotes healing without irritating the sensitive tissue.

Correct Answer: Rich sources of vitamin C

Explanation:

Vitamin C (ascorbic acid) significantly enhances the absorption of non-heme iron (the form of iron found in plant-based foods and iron supplements). Consuming foods rich in vitamin C alongside iron-rich foods improves the efficiency of iron absorption by reducing iron to a more absorbable form in the digestive tract. Examples of vitamin C-rich foods include citrus fruits, strawberries, bell peppers, and broccoli.

Why the Other Options Are Incorrect:

Vitamin E

While vitamin E is important for overall health, it does not play a direct role in promoting the absorption of iron. Iron absorption is primarily influenced by vitamin C and not by vitamin E.

Meat, egg yolks, oysters, and shellfish

While meat, egg yolks, oysters, and shellfish are good sources of heme iron (the form of iron more readily absorbed by the body), this option does not specifically address enhancing iron absorption. The client might already be consuming iron from these sources, but to further enhance absorption, combining them with vitamin C would be more effective.

Sources of vitamin B12

Vitamin B12 is important for red blood cell production but does not directly influence the absorption of iron. Iron deficiency anemia typically requires iron supplementation or dietary changes, not vitamin B12.

Summary:

Rich sources of vitamin C, as vitamin C enhances the absorption of non-heme iron. Other options may provide iron or support overall health, but they do not have the same effect on iron absorption as vitamin C.

Correct Answer: Notify the physician

Explanation:

The presence of loose, tarry, black stool (referred to as melena) is a significant finding that suggests the client may be experiencing gastrointestinal bleeding. This is a potential complication of thrombocytopenia, a condition where the client has a low platelet count, increasing their risk of bleeding. The nurse's primary concern should be the potential for internal bleeding, particularly from the gastrointestinal tract, which may not be immediately visible but can be life-threatening.

The nurse’s priority action is to notify the physician immediately so that appropriate measures can be taken to assess the client’s condition and manage any potential bleeding. The physician will need to assess whether further interventions, such as blood transfusions, coagulation studies, or additional hemostatic treatments, are needed.

Why the Other Options Are Incorrect:

Stop the nosebleed

While controlling the nosebleed is important, the presence of melena indicates there may be a more serious underlying issue, such as internal bleeding, which requires immediate medical attention. Stopping the nosebleed is important, but the priority in this case should be addressing the possible internal bleeding and informing the physician for further evaluation and intervention."

Put in an IV line

While placing an IV line may eventually be necessary for fluid resuscitation or medication administration, the priority action in this situation is not just IV access. The nurse's primary focus should be to notify the physician about the potential for gastrointestinal bleeding, which can lead to shock or other complications. The physician will guide the nurse on the appropriate next steps, which may include IV access.

Ask someone to clean the bedpan

While the bedpan should be cleaned to maintain a clean environment, this is not the priority action in this case. The priority action is to address the potential internal bleeding and notify the physician. Cleaning the bedpan does not address the serious issue of gastrointestinal bleeding, which could be life-threatening.

Summary:

The nurse’s priority action is to notify the physician about the loose, tarry, black stool (melena), which could indicate internal bleeding in a client with thrombocytopenia. The physician will assess the situation and provide guidance on the appropriate treatment. 

Correct Answer: Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints.

Explanation:

Before taking a blood pressure in a client with hemophilia, it is important for the nurse to assess whether the procedure has previously caused bleeding under the skin or in the arm joints. Clients with hemophilia have a deficiency in clotting factors, making them prone to prolonged bleeding. Taking a blood pressure reading can sometimes result in bleeding or hematoma formation, especially if the cuff is inflated too tightly or for too long. Asking about any past bleeding episodes related to blood pressure measurements helps the nurse avoid causing further harm and ensures that proper precautions are taken.

Why the Other Options Are Incorrect:

Ask if taking a blood pressure has ever produced pain in the upper arm.

Pain in the upper arm alone is not a typical concern for a client with hemophilia before taking a blood pressure. The focus should be on bleeding or hematoma formation, not just pain. While pain may occur in the arm for various reasons, it is not a direct indicator of a bleeding risk related to hemophilia.

Ask if taking a blood pressure has ever caused bruising in the hand and wrist.

While bruising could indicate bleeding, bruising in the hand and wrist is not the primary area of concern for hemophilia when taking blood pressure. The arm, particularly the area around the elbow or upper arm, is more likely to be affected during blood pressure measurement.

Ask if taking a blood pressure has ever produced the need for medication.

There is no direct connection between the need for medication and the act of taking a blood pressure in clients with hemophilia. The key concern is preventing bleeding complications, not the need for medication after the procedure. The nurse should focus on the risk of bleeding, not post-procedure medication needs.

Summary:

The most important consideration before taking a blood pressure in a client with hemophilia is ensuring that the procedure does not result in harmful bleeding, particularly under the skin or in the joints. Therefore, Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints is the most appropriate action.