Nokea
A client is admitted to the medical-surgical unit with a report of severe hematemesis. The nurse should give priority to:
- A. Performing an assessment
- B. Obtaining a blood permit
- C. Initiating an IV with a large-bore needle
- D. Inserting an NG tube
Correct Answer: C
Rationale: Severe hematemesis indicates significant bleeding, requiring immediate IV access with a large-bore needle for fluid and blood resuscitation to stabilize the client.
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Which of the following foods, if selected by the mother with a child with celiac, would indicate her understanding of the dietary instructions?
- A. Whole-wheat toast
- B. Angel hair pasta
- C. Reuben on rye
- D. Rice cereal
Correct Answer: D
Rationale: Rice cereal is gluten-free, suitable for celiac disease, unlike wheat-based foods.
The nurse is caring for a patient with a colostomy. The patient asks, 'Will I ever be able to swim again?' The nurse's best response would be:
- A. Yes, you should be able to swim again, even with the colostomy.'
- B. You should avoid immersing the colostomy in water.'
- C. No, you should avoid getting the colostomy wet.'
- D. Don't worry about that. You will be able to live just like you did before.'
Correct Answer: A
Rationale: Swimming is possible with a colostomy if proper precautions, like a waterproof seal, are used to protect the stoma.
The nurse is assessing a client for hypovolemia. Which laboratory result would help the nurse in confirming a volume deficit?
- A. Hematocrit 55%
- B. Potassium 5.0 mEq/L
- C. Urine specific gravity 1.016
- D. BUN 18 mg/dL
Correct Answer: A
Rationale: Hypovolemia causes hemoconcentration, increasing hematocrit (e.g., 55% is elevated). Potassium, urine specific gravity, and BUN within normal ranges don't confirm volume deficit.
The physician has ordered injections of Neumega (oprellvekin) for a client receiving chemotherapy for prostate cancer. Which finding suggests that the medication is having its desired effect?
- A. Hct 12.8 g
- B. Platelets 250,000 mm³
- C. Neutrophils 4,000 mm³
- D. RBC 4.7 million
Correct Answer: B
Rationale: Neumega (oprelvekin) stimulates platelet production, so a platelet count of 250,000 mm³ indicates effectiveness.
A infant weighs 7 pounds at birth. The expected weight by 1 year should be:
- A. 10 pounds
- B. 12 pounds
- C. 18 pounds
- D. 21 pounds
Correct Answer: D
Rationale: Infants typically triple their birth weight by 1 year, so a 7-pound infant should weigh approximately 21 pounds.