Nokea
A 42-year-old female has thrombocytopenia with a platelet count of 75,000. The nurse should
- A. monitor for bleeding.
- B. place the client on neutropenic precautions.
- C. limit visiting hours.
- D. encourage a diet high in iron.
Correct Answer: A
Rationale: Thrombocytopenia (platelets <150,000) increases bleeding risk. Monitoring for bleeding (e.g., bruising, petechiae) is the priority.
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The charge nurse considers both patient-related and staff-related factors when making daily assignments. All of the following are patient-related factors EXCEPT
- A. mechanical ventilation use.
- B. complex medication regimen.
- C. isolation precaution requirements.
- D. nurse-to-client ratio.
Correct Answer: D
Rationale: Nurse-to-client ratio is a staff-related factor, affecting workload distribution. Ventilation, medications, and isolation are patient-specific needs.
A client is admitted to the surgical unit following a transurethral prostatectomy (TURP). The nurse administers a B&O suppository to help prevent bladder spasms. The nurse would observe the client for:
- A. Insomnia and hyperactivity
- B. Physiological dependence on the drug
- C. Nausea and vomiting
- D. Diarrhea and abdominal cramping
Correct Answer: C
Rationale: Belladonna and opium (B&O) suppositories can cause nausea and vomiting as side effects. These are more immediate concerns than dependence or the other symptoms.
An elderly adult has been admitted with a diagnosis of hypertension with a history of dementia. Which of the following nursing diagnoses has the highest priority for this client?
- A. ineffective coping
- B. activity intolerance
- C. ineffective tissue perfusion
- D. risk for injury
Correct Answer: D
Rationale: Dementia increases fall and injury risk due to impaired judgment and memory, making 'risk for injury' the priority.
A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?
- A. Call security for assistance and prepare to sedate the client.
- B. Tell the client to calm down and ask him if he would like to play cards.
- C. Tell the client that if he continues his behavior he will be punished.
- D. Leave the client alone until he calms down.
Correct Answer: A
Rationale: Calling security and preparing for sedation ensures the safety of the client, other patients, and staff during an uncontrolled rage.
A client with pancreatitis has been transferred to the intensive care unit. The nurse assesses a pulmonary arterial wedge pressure (PAWP) of 14 mmHg. Based on this finding, the nurse would want to further assess for:
- A. A drop in blood pressure
- B. Rales on chest auscultation
- C. Complaints of chest pain
- D. Dry mucous membranes
Correct Answer: B
Rationale: A PAWP of 14 mmHg is slightly elevated, suggesting possible fluid overload, which could lead to pulmonary edema, indicated by rales on chest auscultation.