Practice Question
A nurse in an emergency department (ED) is caring for a male client.
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Rationale:
Hematologic System
Limit sitting with legs crossed.
💎Crossing the legs restricts venous return, further impairing circulation in a client already prone to hyperviscosity and thrombosis.
The nurse should encourage frequent movement, leg elevation, and adequate hydration to decrease clotting risk.
💎Low-dose aspirin (if prescribed) helps reduce platelet aggregation, but high-dose therapy increases bleeding risk and should not be initiated without provider order.
💎These measures enhance blood flow and reduce vascular complications associated with PV.
Cardiovascular System
Anticipate an order for therapeutic phlebotomy.
💎Therapeutic phlebotomy is the main treatment for polycythemia vera — it removes blood at regular intervals to lower hematocrit to below 45%, reducing viscosity and cardiac workload.
💎Lowering RBC mass decreases blood pressure, clot formation, and risk of cardiovascular events.
💎The nurse should also maintain oxygen saturation >95% to prevent tissue hypoxia, which could stimulate further erythropoietin release.
💎Regular monitoring of vitals, fluid status, and hematocrit helps evaluate treatment effectiveness.
💎Phlebotomy combined with hydration minimizes hypervolemia and hypertension complications.
Integumentary System
Instruct client to bathe with cool water.
💎Clients with PV often develop aquagenic pruritus, a histamine-mediated itching that worsens with warm water exposure.
💎Bathing in cool or tepid water constricts skin vessels, reducing histamine release and minimizing discomfort.
💎The nurse can also recommend patting skin dry (not rubbing), using soothing lotions, and avoiding hot showers.
💎Topical steroids or antihistamines may be prescribed for additional relief, but environmental control (cool baths) is the first-line nonpharmacologic intervention.
💎Comfort promotion helps prevent scratching-related skin breakdown or infection.
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This question is from Custom-2201 Unit 2 Exam 2025 which contains 61 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI MedSurg
- Answer Choices: 1