Nokea
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 correct answer is A: Bleeding precautions. With low platelets (50,000/ul), the client is at risk for bleeding. Platelets help with blood clotting, so precautions to prevent bleeding are essential. This includes avoiding activities that can cause injury, using a soft toothbrush, and reporting any signs of bleeding.
Summary:
B: Isolation to prevent infection - This is not related to the client's lab values.
C: Seizure precautions - Not relevant to the client's lab values.
D: Control of pain with analgesics - Pain management is not the priority given the client's lab values indicating a risk of bleeding.
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Rehabilitation plans for Mr. Gabatan;
- A. Should be left up to Mr. Gabatan and his family
- B. Should be considered and planned for early in his care
- C. Are not necessary, because he will return to former activities
- D. Are not necessary, because he will probably not able to work again Ms. J.K. is a 24-year old woman admitted to the neurosurgery floor 2 days following a hypophysectomy for a pituitary tumor. She is alert, oriented, and eager to return to her job as an executive to the hospital director. She is alert, oriented and eager to return to her job as an executive assistant to the hospital director. She calls the nurse to her room to express her concern about the frequency of urination she is experiencing, as well as the feeling of weakness that began this morning.
Correct Answer: B
Rationale: The correct answer is B because rehabilitation plans should be considered and planned for early in Mr. Gabatan's care to ensure the best outcomes. By addressing rehabilitation early, healthcare professionals can tailor interventions to his specific needs, promote independence, and prevent complications. This proactive approach enhances Mr. Gabatan's quality of life and functional abilities.
Choices A, C, and D are incorrect:
A: Leaving rehabilitation plans solely up to Mr. Gabatan and his family may not ensure comprehensive care and could lead to delays or inadequate support.
C: Assuming Mr. Gabatan will return to former activities without proper rehabilitation assessment and planning overlooks potential limitations and needs.
D: Assuming Mr. Gabatan will not be able to work again without proper rehabilitation evaluation and interventions may limit his potential for recovery and independence.
A patient who is suspected of having hypothyroidism should be expected which of these symptoms?
- A. tachycardia
- B. hyperthermia
- C. weight loss
- D. extreme fatigue
Correct Answer: D
Rationale: The correct answer is D, extreme fatigue, for a patient suspected of having hypothyroidism. Hypothyroidism is associated with decreased production of thyroid hormones, leading to a slower metabolism and reduced energy levels. This results in symptoms such as fatigue, weakness, and lethargy. Tachycardia (A) is more commonly associated with hyperthyroidism, where the thyroid is overactive. Hyperthermia (B) is increased body temperature, not typically a symptom of hypothyroidism. Weight loss (C) is also more commonly seen in hyperthyroidism due to increased metabolism. In summary, extreme fatigue is a hallmark symptom of hypothyroidism due to decreased thyroid hormone levels, distinguishing it from the other choices.
While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?
- A. Tell the patient to just focus on the leg and cast right now.
- B. Document the sleep patterns and information in the patient’s chart.
- C. Explain that a more thorough assessment will be needed next shift.
- D. Ask the patient about usual sleep patterns and the onset of having difficulty resting.
Correct Answer: D
Rationale: The correct answer is D: Ask the patient about usual sleep patterns and the onset of having difficulty resting.
Rationale:
1. Establish rapport: Asking about usual sleep patterns shows empathy and builds rapport.
2. Holistic assessment: Understanding sleep patterns helps identify potential issues beyond the leg cast.
3. Gather information: Knowing the onset of sleep difficulty can reveal underlying causes.
4. Patient-centered care: Addressing sleep concerns aligns with patient needs.
Incorrect answers:
A: Focusing solely on the leg and cast disregards the patient's holistic well-being.
B: Documenting without addressing the patient's concern neglects the opportunity for intervention.
C: Delaying assessment till the next shift can worsen the patient's condition and delay appropriate care.
A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change?
- A. Purplish stools
- B. Redness of the upper part of the feet
- C. Bluish urine
- D. Coldness of the soles
Correct Answer: C
Rationale: The correct answer is C: Bluish urine. During lymphangiography, a contrast dye is injected into the lymphatic vessels, which can be excreted through the urine, causing it to appear bluish temporarily. This change is harmless and resolves on its own.
Incorrect Answers:
A: Purplish stools - This is not a common side effect of lymphangiography.
B: Redness of the upper part of the feet - Redness is not typically associated with this procedure.
D: Coldness of the soles - Coldness is not a known temporary change resulting from lymphangiography.
After the surgical incision has been clised and the anesthesia has wear-off, the patient is extubated and transferred to the postanesthesia care unit (PACU). Who is responsible for transferring the patient?
- A. Circulating nurse
- B. scrub nurse
- C. surgeon
- D. anesthesiologist
Correct Answer: D
Rationale: The correct answer is D: anesthesiologist. The anesthesiologist is responsible for transferring the patient to the PACU as they are in charge of the patient's anesthesia management throughout the surgery. They are trained to assess the patient's condition post-surgery, manage any immediate postoperative complications, and ensure a smooth transition to the PACU staff for continued care. The circulating nurse (A) is responsible for managing the operating room environment, the scrub nurse (B) assists the surgeon during the surgery by passing instruments, and the surgeon (C) performs the surgical procedure but does not typically transfer the patient to the PACU.