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A 72-year-old client with cancer needs assistance with paying hospital bills. The nurse should refer the client to a:
- A. Bank representative.
- B. Social worker.
- C. Loan officer.
- D. Representative of the hospital billing department.
Correct Answer: B
Rationale: A social worker can connect the client with financial assistance programs and resources to help manage hospital bills.
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A nurse is providing postmortem care for a client who has died of cancer. The most appropriate action is to:
- A. Remove all medical equipment immediately.
- B. Leave the body uncovered for family viewing.
- C. Bathe the body and position it respectfully.
- D. Notify the family to collect belongings quickly.
Correct Answer: C
Rationale: Bathing and positioning the body respectfully prepares it for family viewing and honors the deceased, aligning with postmortem care standards.
The nurse is observing a client who is recovering from back strain lift a box as shown below. What should the nurse do?
- A. Praise the client for using correct body mechanics.
- B. Suggest to the client that she put both knees on the floor before attempting to lift the box.
- C. Advise the client to bend from the waist rather than stretching her back in this position.
- D. Inform the client that she should keep her back straight by squatting with both knees parallel.
Correct Answer: A
Rationale: The client is using correct body mechanics for lifting because she is keeping her back as straight as possible and is holding the box close to her body. She is using her large leg muscles to lift the box. She is using a broad base of support by placing her feet as wide apart as possible. The other suggestions would cause the client to put a strain on her back.
A client receives a thrombolytic agent. The expected outcome of this drug therapy includes:
- A. Improved cerebral perfusion
- B. Decreased vascular permeability
- C. Dissolved emboli
- D. Prevention of further cerebral hemorrhage
Correct Answer: C
Rationale: Thrombolytic agents (e.g., alteplase) dissolve existing clots, such as emboli in pulmonary embolism or arterial occlusion, restoring blood flow. They do not improve cerebral perfusion, decrease vascular permeability, or prevent cerebral hemorrhage (they increase bleeding risk).
A client undergoing chemotherapy has a white blood cell count of 2300/mm³; hemoglobin of 9.8 g/dL; platelet count of 80,000/mm³ and potassium of 3.8. Which of the following should take priority?
- A. Blood pressure 136/88.
- B. Emesis of 90 mL.
- C. Temperature 101°F (38.3°C).
- D. Urine output 40 mL/hour.
Correct Answer: C
Rationale: A fever of 101°F in a neutropenic client (WBC 2300/mm³) indicates a high risk of infection, which is a priority due to potential for rapid deterioration.
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?
- A. Cholesterol level.
- B. Pupil size and pupillary response.
- C. Bowel sounds.
- D. Echocardiogram. SUPPRESSED
Correct Answer: B
Rationale: Pupil size and pupillary response are priority assessments to detect neurological deterioration, such as increased ICP or stroke extension. Cholesterol, bowel sounds, and echocardiograms are not immediate priorities.