Nokea
A client has an absolute neutrophil count (ANC) of 500/mm³ (0.5 x 10â¹/L) after completing chemotherapy. Which intervention is most important for the nurse to implement?
- A. Review need for pneumococcal vaccine.
- B. Implement bleeding precautions.
- C. Assess vital signs every 4 hours.
- D. Place the client in protective isolation.
Correct Answer: D
Rationale: Placing the client in protective isolation is the most important intervention to prevent infections, as a low ANC indicates a high risk of bacterial and fungal infections.
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After initiating a steroid nebulizer treatment for a client with asthma in respiratory distress, which intervention is most important for the nurse to implement?
- A. Monitor pulse oximetry every 2 hours.
- B. Teach proper use of a rescue inhaler.
- C. Elevate the head of bed to 90 degrees.
- D. Determine exposure to asthmatic triggers.
Correct Answer: C
Rationale: Elevating the head of bed to 90 degrees improves breathing and oxygenation by reducing pressure on the diaphragm, increasing lung expansion, and facilitating mucus expectoration.
History and physical
Flow sheet
Nurses’ Notes
Imaging studies 1935
A 70-year-old female presents to the emergency department through triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the patient’s husband noticed his wife’s speech became difficult to understand
Specify which findings indicate early interventions for an ischemic stroke were effective? Focused assessment area: Neurological, Muscoskeletal, Psychosocial
- A. Neurological: Drinks with repetitive cough, Speaks in short sentences, Decorticate posturing; Muscoskeletal: Flaccidity of left arm, Ambulates with a walker, Passive range of motion on left leg; Psychosocial: Fits of laughter, Tearful sharing of stories, Angry outburst
- B. Neurological: Speaks in short sentences; Muscoskeletal: Ambulates with a walker; Psychosocial: Tearful sharing of stories
Correct Answer: B,B,B
Rationale: Neurological: Speaking in short sentences indicates improved speech from garbled to intelligible. Muscoskeletal: Ambulating with a walker shows regained mobility. Psychosocial: Tearful sharing of stories reflects normal emotional expression and preserved memory, indicating effective early interventions.
After performing a head-to-toe assessment for a client with Addison's disease, the nurse reports findings to the healthcare provider. The findings include moist mucous membranes, strong palpable peripheral pulses, and blood pressure 132/88 mm Hg. The client verbalizes understanding of the illness and importance of taking medications every day. Which action should the nurse implement?
- A. Make a referral for social services at home.
- B. Continue to limit daily fluid intake to 500 mL.
- C. Begin preparing the client for discharge home.
- D. Recommend strict intake and output monitoring.
Correct Answer: C
Rationale: Preparing the client for discharge home is the best action for the nurse to implement, as the client has no signs of complications or deterioration from Addison's disease. The client should be able to manage the condition at home with regular follow-up and medication adherence.
A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid. The client develops a rigid abdomen with rebound tenderness. Which action should the nurse take?
- A. Measure capillary glucose level.
- B. Encourage ambulation in the room.
- C. Monitor for bloody diarrheal stools.
- D. Obtain vital sign measurements.
Correct Answer: D
Rationale: Obtaining vital sign measurements is the priority action for a client with a rigid abdomen and rebound tenderness, indicating peritonitis, a serious complication of IBD. Vital signs can reveal signs of infection, inflammation, shock, and organ failure, guiding appropriate interventions and treatments.
The healthcare provider prescribes 1 liter of 0.9% sodium chloride, USP intravenously (IV) to be infused over 10 hours for a client. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)
- A. 100
Correct Answer: 100
Rationale: To deliver 1000 mL over 10 hours, the rate is calculated as 1000 mL / 10 hr = 100 mL/hr.