Nokea
A client is scheduled for an elective laparoscopic prostatectomy in the morning. The practical nurse should notify the registered nurse about which of the following assessment data as soon as possible before surgery?
- A. INR level
- B. platelet count
- C. hemoglobin and hematocrit levels
- D. temperature 100.4 F (38 C) with cough
Correct Answer: D
Rationale: A temperature of 100.4 F with cough suggests a possible infection, which could contraindicate surgery due to increased risk of complications.
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A 2 month-old child has had a cleft lip repair. The selection of which restraint would require no further action by the charge nurse?
- A. Elbow
- B. Mummy
- C. Jacket
- D. Clove hitch
Correct Answer: A
Rationale: Elbow. The elbow restraint will prevent the child from touching the surgical site without hindering movement of other parts of the body.
The daughter of a 78-year-old woman asks the nurse why her mother is giving away some of her belongings to her children and grandchildren. What should the nurse include when responding?
- A. Older adults usually become more generous.
- B. It is normal for older adults to think about and prepare for their own death.
- C. Her mother probably does not trust her children to divide her things appropriately.
- D. Her mother is probably thinking about suicide.
Correct Answer: B
Rationale: Giving away belongings reflects preparation for death, a normal developmental task in older adults achieving ego integrity. Generosity, distrust, or suicide are less likely.
A client with leukemia has been receiving injections of Neulasta (pegfilgrastim). Which laboratory value reveals that the drug is producing the desired effect?
- A. Hemoglobin of $13.5 \mathrm{~g} / \mathrm{dL}$
- B. White blood cell count of $6,000 / \mathrm{mm}$
- C. Platelet count of $300,000 / \mathrm{mm}$
- D. Iron level of $75 \mu \mathrm{g} / \mathrm{dL}$
Correct Answer: B
Rationale: Neulasta (pegfilgrastim) stimulates the production of neutrophils, a type of white blood cell, to reduce the risk of infection in clients with neutropenia. A white blood cell count of 6,000/mm indicates an increase in white blood cells, showing the drug's desired effect. Hemoglobin relates to red blood cells, platelet count relates to clotting, and iron level is unrelated to Neulasta's action.
The nurse auscultates the heart sounds of a 77-year-old client with chronic heart failure. Which heart sound should the nurse document?
- A. Pericardial friction rub
- B. S1, S2, no adventitious sounds
- C. S3 extra heart sound
- D. Systolic murmur
Correct Answer: C
Rationale: An S3 heart sound is commonly associated with heart failure due to fluid overload and ventricular dysfunction.
An anxious parent of a 4 year-old consults the nurse for guidance in how to answer the child's question, 'Where do babies come from?' What is the nurse's best response to the parent?
- A. When a child asks a question, give a simple answer.
- B. Children ask many questions, but are not looking for answers.
- C. This question indicates interest in sexual development.
- D. Full and detailed answers should be given to all questions.
Correct Answer: A
Rationale: When a child asks a question, give a simple answer. Honesty is important, but answers should be simple and age-appropriate, providing only the information the child is ready to understand.