Nokea
A client begins a regimen of chemotherapy. Her platelet counts falls to 98,000. Which action is least likely to increase the risk of hemorrhage?
- A. Test all excreta for occult blood.
- B. Use a soft toothbrush or foam cleaner for oral hygiene.
- C. Implement reverse isolation.
- D. Avoid IM injections.
Correct Answer: C
Rationale: Reverse isolation does not affect the risk of hemorrhage.
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Teaching the client with gonorrhea how to prevent reinfection and further spread is an example of:
- A. primary prevention.
- B. secondary prevention.
- C. tertiary prevention.
- D. primary health care prevention.
Correct Answer: B
Rationale: Secondary prevention targets the reduction of disease prevalence and disease morbidity through early diagnosis and treatment.
Clients who take iron preparations should be warned of the possible side effects, which might include:
- A. dizziness and orthostatic hypotension
- B. nausea, vomiting, diarrhea or constipation, and stomach cramps
- C. drowsiness, lethargy, and fatigue
- D. neuropathy and tingling in the extremities
Correct Answer: B
Rationale: Iron supplements commonly cause gastrointestinal side effects like nausea, vomiting, diarrhea, constipation, and stomach cramps, requiring client education.
A client newly diagnosed with Diabetes Mellitus needs education. Which of the following statements should the nurse include in this education?
- A. You can eat anything you want, but no foods with sugar.'
- B. You need to lose weight, so your diet must be a restricted one.'
- C. You need a diet and exercise program.'
- D. You must eliminate all salt, fat, and sugar from your diet.'
Correct Answer: C
Rationale: A balanced diet and exercise program are essential for managing diabetes, promoting glycemic control and overall health without extreme restrictions.
Assessment of the client with an arteriovenous fistula for hemodialysis should include:
- A. inspection for visible pulsation.
- B. palpation of thrill.
- C. percussion for dullness.
- D. auscultation of blood pressure.
Correct Answer: B
Rationale: Thrill should be present. The client should be taught to check this daily at home. Pulsation is not typically visible. Percussion gives no information about the patency of a fistula. Blood pressure is not auscultated in a limb with an AVF. Auscultation of the AVF, for a bruit, is part of an assessment for patency.
A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client's weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as:
- A. within normal limits, so a weight-reduction diet is unnecessary.
- B. lower than normal, so education about nutrient-dense foods is needed.
- C. indicating obesity because the BMI is 35.
- D. indicating overweight status because the BMI is 27.
Correct Answer: C
Rationale: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. It is calculated by utilizing a chart or nomogram that plots height and weight. This client's BMI is 35, indicating obesity. Goals of diet therapy are aimed at decreasing weight and increasing activity to healthy levels based on a client's BMI, activity status, and energy requirements.