Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider?
Presence of plethora (excess body fluid)
Calf swelling and pain
Platelet count 450,000/microL
Hematocrit 55%
The Correct Answer is B
A. Presence of plethora is a common symptom of polycythemia vera and indicates increased blood volume but is not immediately life-threatening.
B. Calf swelling and pain could indicate a deep vein thrombosis (DVT), which is a serious complication that requires immediate medical attention.
C. A platelet count of 450,000/microL is elevated but not as critical as the possibility of a DVT.
D. Hematocrit of 55% is high, which is expected in polycythemia vera, but it is not as immediately critical as the risk of thrombosis suggested by calf swelling and pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Monitor fluid intake and output. Monitoring fluid intake and output is essential in patients with multiple myeloma to assess for signs of dehydration or fluid overload, which can occur due to renal complications.
B. Limit weight bearing and ambulation. Limiting weight bearing and ambulation is not a
standard intervention for multiple myeloma unless there are specific complications such as bone fractures.
C. Assess lymph nodes for enlargement. Multiple myeloma primarily affects the bone marrow and plasma cells, not the lymph nodes.
D. Administer calcium supplements. While calcium supplementation may be necessary in some cases of multiple myeloma, it is not a priority action upon admission without further assessment.
Correct Answer is C
Explanation
A. Using a water-based lubricant during sexual activity can help reduce discomfort or vaginal dryness, which may occur after a hysterectomy.
B. After a total abdominal hysterectomy, menstrual periods will cease because the uterus, and often the ovaries, are removed during the procedure.
C. Taking a tub bath instead of a shower is not recommended after a total abdominal
hysterectomy and vaginal repair. Bathing in a tub can increase the risk of infection, especially if the surgical incisions are still healing. The client should avoid submerging the surgical site in water until it has fully healed and cleared by their healthcare provider.
D. Increasing intake of protein and vitamin C can support wound healing and overall recovery after surgery. This statement indicates appropriate understanding of postoperative care.
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