Which nursing intervention(s) should be employed when caring for the bone marrow donor immediately following a bone marrow aspiration? (SELECT ALL THAT APPLY)
Administer aspirin for bone pain
Place the client in high Fowler's position
Apply direct pressure to the puncture site
Assess and document vital signs
Initiate neutropenic precautions
Correct Answer : C,D
A. Aspirin can increase the risk of bleeding and is typically contraindicated in patients who have undergone procedures like bone marrow aspiration. Instead, acetaminophen may be recommended for pain relief, as it does not have blood-thinning effects.
B. After a bone marrow aspiration, the donor is typically advised to lie flat or in a comfortable position to minimize discomfort and reduce the risk of bleeding. High Fowler's position may not provide the necessary comfort or support needed post-procedure.
C. Applying direct pressure to the puncture site is a critical intervention to minimize bleeding and promote clotting at the site of the aspiration. The nurse should apply pressure for a sufficient amount of time as per protocol.
D. Monitoring vital signs is important after any invasive procedure to detect any complications early, such as bleeding or signs of shock. Documenting vital signs also ensures continuity of care.
E. This choice is not applicable immediately after bone marrow aspiration for a donor. Neutropenic precautions are typically implemented for patients who have low white blood cell counts due to chemotherapy or other conditions. Bone marrow donors do not require these precautions immediately after donation unless there is a specific concern for infection or a significant drop in white blood cell counts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. CA-125 is primarily associated with ovarian cancer and is not a relevant tumor marker for testicular cancer. Serum ceruloplasmin is a copper-carrying protein that can be elevated in various conditions, but it is not specific for testicular cancer. Therefore, this option is not appropriate.
B. Both hCG and AFP are tumor markers specifically associated with testicular cancer. Elevated levels of these markers can indicate the presence of non-seminomatous testicular tumors. Monitoring these markers is essential for diagnosis, assessing treatment response, and detecting recurrence.
C. EPO is involved in red blood cell production and is not a tumor marker for testicular cancer. CEA is primarily associated with colorectal cancer and some other malignancies, but it is not specific for testicular cancer.
D. PSA is a tumor marker associated with prostate cancer, not testicular cancer. While hCG is relevant for testicular cancer, the inclusion of PSA makes this option inappropriate for a client with testicular cancer.
Correct Answer is ["7"]
Explanation
(desired dose * volume of solution) / (concentration of drug * time) = rate.
For an infusion of 7 units per hour with a concentration of 100 units in 100 mL, the calculation would be: (7 units/hour * 100 mL) / (100 units * 1 hour) = 7 mL/hour.
Therefore, the nurse should set the IV pump to 7 mL per hour to deliver a continuous infusion of insulin at the prescribed rate.
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