A nurse in a hematology clinic is working with four clients who ...

[SO00]

A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client should the nurse see first?
 
  a. Client with a blood pressure of 180/98 mm Hg
  b. Client who reports shortness of breath
  c. Client who reports calf tenderness and swelling
  d. Client with a swollen and painful left great toe

Question 2

The family of a neutropenic client reports the client is not acting right. What action by the nurse is the priority?
 
  a. Ask the client about pain.
  b. Assess the client for infection.
  c. Delegate taking a set of vital signs.
  d. Look at today's laboratory results.

[Beatricemm]

Answer to Question 1

ANS: B
Clients with polycythemia vera often have clotting abnormalities due to the hyperviscous blood with sluggish flow. The client reporting shortness of breath may have a pulmonary embolism and should be seen first. The client with a swollen calf may have a deep vein thrombosis and should be seen next. High blood pressure and gout symptoms are common findings with this disorder.

Answer to Question 2

ANS: B
Neutropenic clients often do not have classic manifestations of infection, but infection is the most common cause of death in neutropenic clients. The nurse should assess for infection. The nurse should assess for pain but this is not the priority. The nurse should take the client's vital signs instead of delegating them since the client has had a change in status. Laboratory results may be inconclusive.