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A client has the following blood lab values: platelets 50,000/ul, RBC's 3.5 (X 106), hemoglobin 10 g/dl, hematocrit 30 percent, WBCs 10,000/ul. Which nursing instruction should be included in the teaching plan?
- A. Bleeding precautions
- B. Isolation to prevent infection
- C. Seizure precautions
- D. Control of pain with analgesics
Correct Answer: A
Rationale: The client's platelet count of 50,000/ul is significantly low (normal range is around 150,000-450,000/ul). A low platelet count places the client at risk for bleeding tendencies. Therefore, the most appropriate nursing instruction to include in the teaching plan is bleeding precautions. This would involve educating the client on measures to prevent bleeding such as avoiding activities that may cause injury, using a soft toothbrush, avoiding tight clothing, and being cautious while shaving.
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A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's plan of care?
- A. Avoiding using a soap on the irradiated areas
- B. Applying talcum powder to the irradiated areas daily after bathing
- C. Wearing a lead apron during direct contact with the client
- D. Removing thoracic skin markings after each radiation treatment
Correct Answer: A
Rationale: The correct intervention that should be part of the plan of care for a client at risk for impaired skin integrity due to external radiation is avoiding using a soap on the irradiated areas. Soap can be drying to the skin and may exacerbate skin reactions caused by radiation therapy. It is important to keep the skin in the radiation field clean, but avoiding soap will help prevent further irritation and damage to the skin. Instead, a gentle cleanser recommended by the healthcare provider should be used to clean the irradiated areas. Additionally, maintaining good hydration and moisturizing the skin as recommended by the healthcare team can also help minimize skin reactions.
A 50-year old male was brought toi the emergency department with a diagnosis of diabetes insipidus. The client had a posterior pituitary tumor. The nursing diagnosis most appropriate for this client is:
- A. fluid volume excess
- B. incontinence, bowel
- C. fluid volume deficit
- D. diarrhea
Correct Answer: C
Rationale: Diabetes insipidus is a condition characterized by excessive thirst and excretion of large amounts of dilute urine, resulting in fluid volume deficit. The posterior pituitary tumor in this case is likely causing decreased secretion of antidiuretic hormone (ADH), leading to the inability of the kidneys to concentrate urine and retain water. This imbalance results in the loss of fluid, leading to dehydration and electrolyte imbalances. Therefore, the most appropriate nursing diagnosis for this client is fluid volume deficit, as the priority is to address the dehydration and restore fluid balance to prevent further complications.
A client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:
- A. E-rosette immunofluorescence
- B. Enzyme-linked immunosorbent assay
- C. Quantification of T-lymphocytes (ELISA)
- D. Western blot test with ELISA
Correct Answer: D
Rationale: The confirmatory test for HIV infection is a Western blot test. However, before a Western blot test is conducted, an initial screening test with high sensitivity, such as the enzyme-linked immunosorbent assay (ELISA), is typically performed. ELISA is used to detect the presence of HIV antibodies in the blood. If the ELISA test is positive, a Western blot test is then performed to confirm the presence of specific HIV antibodies. The Western blot test is a more specific test for HIV antibodies and is used to confirm the diagnosis. Therefore, in this case, the physician would most likely order a Western blot test following a positive ELISA test to confirm the client's HIV infection.
Approximately how much fluid is lost in acute weight loss of .5kg?
- A. 50 ml
- B. 750 ml
- C. 500 ml
- D. 75 ml
Correct Answer: C
Rationale: When a person loses 0.5 kg of weight, it is commonly assumed that most of the weight loss is due to fluid loss. The approximate fluid loss for every 0.5 kg of weight loss is around 500 ml. This estimation is based on the fact that 1 kg of body weight is approximately equivalent to 1 liter of fluid. Therefore, for a 0.5 kg weight loss, the fluid loss would be approximately 500 ml (0.5 liters).
Nurse Lina gives discharge instructions to Aling Maria, who is experiencing an exacerbation of COPD because of an upper respiratory tract infection, regarding her diet at home. Which of the following food choices would be appropriate?
- A. low fat low cholesterol
- B. low sodium diet
- C. bland soft diet
- D. high calorie high protein
Correct Answer: D
Rationale: A patient experiencing an exacerbation of COPD, especially due to an infection, requires a diet that is high in calories and protein. This is because during exacerbations, the body's energy requirements increase due to increased work of breathing and inflammation. High-calorie intake helps provide the necessary energy for breathing and healing. Additionally, a high-protein diet is important for maintaining respiratory and skeletal muscle strength, which can be affected during exacerbations of COPD. Therefore, a high-calorie high-protein diet would be most appropriate for Aling Maria to support her recovery and overall health during this period.