Nokea
A 57-year-old man admitted with metastatic cancer has been receiving chemotherapy for 3 months. His lab values include: RBC 3.8 million/mm³, WBC 2,000/mm³, Hgb 9.3 g/dL, platelets 50,000/mm³. Which of the following nursing diagnoses is MOST appropriate for this patient?
- A. Decreased cardiac output.
- B. Ineffective thermoregulation.
- C. Risk for injury.
- D. Ineffective airway clearance.
Correct Answer: C
Rationale: due to low platelet count, normal platelets 150,000-400,000/mm³, decrease causes problems with blood clotting
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An abdominal wound irrigation with a normal saline solution is ordered for a client. To perform this procedure, the nurse should
- A. warm the irrigating solution to 110°F (43.3°C).
- B. establish a sterile field that includes the irrigating equipment.
- C. direct the irrigating solution at the outer edges of the wound, then the center of the wound.
- D. aspirate the irrigating fluid with a syringe to prevent accumulation in the wound.
Correct Answer: B
Rationale: requires strict aseptic technique
The nurse is caring for a postoperative patient. Four hours after surgery, the patient voids 200 cc of urine with a specific gravity of 1.019. The nurse should
- A. palpate the patient's lower abdomen for distention.
- B. encourage an increased intake of oral fluids.
- C. record the time and the amount of urine.
- D. encourage the patient to void again in two hours.
Correct Answer: C
Rationale: amount and specific gravity normal (1.010-1.030)
On a home health visit, an elderly client states, 'This neighborhood has really gone down. I feel like a prisoner in my own home with all the trouble out there.' Which of the following nursing responses by the nurse is BEST?
- A. Have you and your neighbors formed a neighborhood watch?
- B. It must be very difficult for you to live in this neighborhood.
- C. I see a lot of police cars, so you should be pretty safe.
- D. Tell me what has happened to make you feel that you are not safe.
Correct Answer: D
Rationale: assessing the basis for client's fears and encouraging client to talk about them is the first positive step
The physician prescribes cimetidine (Tagamet) 300 mg PO qid for a 75-year-old man. The nurse instructs the client about the medication. Which of the following statements, if made by the client, would indicate that further teaching is needed?
- A. I'll take this pill with meals and before bed.
- B. I may experience mild diarrhea for a while.
- C. My stools may change color while I'm on this medication.
- D. I should call my doctor if I get an acne-like rash.
Correct Answer: C
Rationale: no change in stool color
An 8-year-old boy is brought to the physician’s office by his mother. The mother is concerned because the boy has a fever, vomited twice, and slept all day yesterday with the curtains closed. The boy complains of headache, nausea, and has a temperature of 103°F (39.3°C). The nurse observes the boy has a petechial rash on the trunk of his body. Which of the following assessments would be MOST important for the nurse to perform?
- A. Grasp the child’s hands and ask him to squeeze the nurse’s hands.
- B. Stroke the plantar surface of the child’s foot with a reflex hammer.
- C. Gently flex the child’s head and neck onto the chest.
- D. Have the child stand with his eyes closed, his arms at his sides, and his feet and knees close together.
Correct Answer: C
Rationale: Fever, headache, nausea, and petechial rash suggest meningitis; flexing the neck (Brudzinski’s sign) assesses meningeal irritation, a priority. Options A, B, and D are less relevant: hand squeeze is nonspecific, Babinski’s sign is not indicated, and Romberg’s sign assesses balance.