The nurse is performing an assessment on a client who was just brought to the ED complaining of fatigue. Upon assessment, the nurse observes a large amount of bruising on the extremities, fever, and tenderness localized in the left upper quadrant. A health history reveals frequent infections for the past 2 months. Laboratory tests indicate severe anemia, significant neutropenia, and thrombocytopenia. Based on the symptoms, what could be the client’s diagnosis? 

Which statement by a 32-year old client newly diagnosed with Stage I breast cancer indicates to the nurse that the client understands her role in planning care? 

Identify which laboratory test should be ordered for each client complaint. Each laboratory test can only be used 1 time.

The nurse is monitoring a client who has a transdermal fentanyl patch in place for pain control related to cancer.  The nurse is teachng the new graduate nurse about interventions when administering this medication. The nurse knows the teaching was effective when the new graduate nurse states the following?    

The nurse is preparing to assess a client whose chart documents that the client experienced extravasation when receiving the vesicant vincristine during the previous shift 4 hours ago. The documentation also notes that an antidote was administered immediately. The nurse prepares to assess the skin for which finding?  

You are administering heparin and following the protocol below for a client weighing 251 lbs. The order is to administer an initial heparin IV bolus followed by a titrated IV infusion.  Round to the tenths place. HEPARIN PROTOCOL Initial bolus- 60 units/kg Initial rate – 12 units/kg/h Obtain a PTT every 6 hours, and adjust dosage and rate as follows: If a PTT is less than 35 secs:      Repeat bolus with 40 units/kg and increase the rate by 4 units/kg/h. If a PTT is 36 to 44 seconds:       If a PTT is 36 to 44 seconds:          Repeat bolus with 20 units/kg and increase the rate by 2 units/kg/h. If a PTT is 45 to 75 seconds:       Continue current rate. If a PTT is 76 to 90 seconds:       Decrease rate by 2 units/kg/h. If a PTT is greater than 90 secs: Hold the heparin for 1 hour and decrease rate by 3 units/kg/h. Available (for bolus)  – heparin 1,000 units/mLAvailable (for infusion) –  heparin 25,000 units in 250 mL D5W What rate will the nurse set the pump at for the initial titrated heparin IV infusion?

A 20-year-old states “I don’t know where this swelling here in my chest came from.”  The nurse palpates an enlarged lymph node on the right side of the sternum . What is the nurse suspicious of?

Applying the nursing process, what is the nurse’s best independent intervention to evaluate the outcome of tracheostomy suctioning immediately following the suctioning?

You are administering heparin and following the protocol below for a client weighing 251 lbs. The order is to administer an initial heparin IV bolus followed by a titrated IV infusion.  Round to the tenths place. HEPARIN PROTOCOL Initial bolus- 60 units/kg Initial rate – 12 units/kg/h Obtain a PTT every 6 hours, and adjust dosage and rate as follows: If a PTT is less than 35 secs:      Repeat bolus with 40 units/kg and increase the rate by 4 units/kg/h. If a PTT is 36 to 44 seconds:       If a PTT is 36 to 44 seconds:          Repeat bolus with 20 units/kg and increase the rate by 2 units/kg/h. If a PTT is 45 to 75 seconds:       Continue current rate. If a PTT is 76 to 90 seconds:       Decrease rate by 2 units/kg/h. If a PTT is greater than 90 secs: Hold the heparin for 1 hour and decrease rate by 3 units/kg/h. Available (for bolus)  – heparin 1,000 units/mLAvailable (for infusion) –  heparin 25,000 units in 250 mL D5W How many mL of heparin will the client receive for the initial IV bolus?

As the home health nurse, you are taking an admission history for a client who has deep vein thrombosis (DVT) and is taking warfarin 2 mg. daily. Which statement by the client is the best indicator that additional teaching about warfarin may be needed?