The nurse understands that a client who has had a bone marrow aspiration to assist in the diagnosis of aplastic anemia requires additional teaching when they state:
I can have aspirin 650 mg for pain when the procedure is over.
The nurse will check the puncture site at least every 4 hours after the procedure.
I will have some pain that is similar to a toothache.
I understand that this is a sterile procedure.
The Correct Answer is A
Choice A reason: The client requires additional teaching if they state that they can have aspirin for pain after the bone marrow aspiration. Aspirin is a drug that inhibits platelet aggregation and increases the risk of bleeding. ¹ The client should avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) for at least 48 hours after the procedure. ² The client should use acetaminophen or another pain reliever that does not affect blood clotting.
Choice B reason: The client does not require additional teaching if they state that the nurse will check the puncture site at least every 4 hours after the procedure. This is a correct statement, as the nurse should monitor the site for signs of bleeding, infection, or hematoma. ² The nurse should also apply pressure and a sterile dressing to the site and instruct the client to keep it dry and clean for 24 hours.
Choice C reason: The client does not require additional teaching if they state that they will have some pain that is similar to a toothache. This is a correct statement, as the client may experience mild to moderate pain at the site of the aspiration, which may radiate to the hip or back. ² The pain usually subsides within a few hours or days.
Choice D reason: The client does not require additional teaching if they state that they understand that this is a sterile procedure. This is a correct statement, as the bone marrow aspiration is performed under sterile conditions to prevent infection. ² The nurse should wear gloves, gown, mask, and eye protection and use a sterile needle, syringe, and antiseptic solution.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Placing the call bell in reach of the client is the most appropriate nursing action following the administration of metoprolol, a beta-blocker that lowers blood pressure and heart rate. ¹ The client may experience dizziness, lightheadedness, or fainting as side effects of the medication, especially after the first dose. ² The call bell allows the client to alert the nurse if they need assistance or experience any adverse reactions.
Choice B reason: Taking a pulse oximetry reading is not the most appropriate nursing action following the administration of metoprolol. Pulse oximetry measures the oxygen saturation of the blood, which is not directly affected by metoprolol. ³ A more relevant vital sign to monitor is the blood pressure and heart rate, which can indicate the effectiveness and safety of the medication.
Choice C reason: Recording the client's weight is not the most appropriate nursing action following the administration of metoprolol. Weight is not a sensitive indicator of the immediate effects of metoprolol. Weight may be monitored periodically to assess the client's fluid status and possible signs of heart failure, which metoprolol can help prevent. ¹ However, this is not a priority action after the first dose of the medication.
Choice D reason: Encouraging oral fluids is not the most appropriate nursing action following the administration of metoprolol. Oral fluids may help prevent dehydration and constipation, which can occur as side effects of metoprolol. ² However, excessive fluid intake may worsen the client's blood pressure and heart function, which metoprolol aims to improve. The nurse should advise the client to drink fluids as directed by the provider and report any signs of fluid overload, such as swelling, shortness of breath, or weight gain.
Correct Answer is C
Explanation
Choice A reason: This is not the best nursing action. Documenting the pulse rate and administering the medications as prescribed may be harmful to the client. Atenolol and diltiazem are both medications that lower the blood pressure and the heart rate. Atenolol is a beta blocker that blocks the effects of adrenaline on the heart and blood vessels. Diltiazem is a calcium channel blocker that relaxes the muscles of the heart and blood vessels. Giving both medications to a client who already has a low and irregular heart rate may cause further bradycardia, which is a heart rate below 60 beats/minute, or arrhythmia, which is an abnormal heart rhythm. The nurse should check the parameters and the contraindications for the medications before administering them.
Choice B reason: This is not the best nursing action. Assessing for chest pain and administering atenolol if pain free may not be appropriate for the client. Chest pain can be a sign of angina or myocardial infarction, which are conditions where the blood flow to the heart is reduced or blocked. Atenolol can help relieve chest pain by reducing the oxygen demand of the heart, but it can also lower the heart rate and the blood pressure. The client already has a low and irregular heart rate, which may indicate a problem with the electrical conduction of the heart. The nurse should not give atenolol without checking the pulse rate and the blood pressure, and consulting the health care provider.
Choice C reason: This is the best nursing action. Holding the atenolol and administering the diltiazem is the most appropriate for the client. Atenolol can lower the heart rate and the blood pressure, which may worsen the client's condition. The nurse should hold the atenolol and notify the health care provider of the client's pulse rate and rhythm. Diltiazem can also lower the heart rate and the blood pressure, but it can also help regulate the heart rhythm by slowing down the electrical impulses in the heart. The nurse should administer the diltiazem as prescribed, and monitor the client's vital signs and cardiac status.
Choice D reason: This is not the best nursing action. Withholding the medications and reassessing the heart rate in 30 minutes may delay the treatment and the care of the client. The client has a low and irregular heart rate, which may indicate a serious cardiac problem that needs immediate attention. The nurse should not wait for 30 minutes to reassess the heart rate, but rather act promptly and notify the health care provider. The nurse should also administer the diltiazem as prescribed, unless there is a specific reason to withhold it.
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