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A client is scheduled for knee replacement surgery, and the nurse is reviewing preoperative laboratory results. The nurse should notify the physician about which of the following abnormal laboratory results?
- A. Platelets 119,000.
- B. Glucose 83.
- C. Hemoglobin 13.7.
- D. Sodium 141.
Correct Answer: A
Rationale: A platelet count of 119,000 (A) is below the normal range (150,000-450,000), increasing bleeding risk during surgery, and should be reported. Glucose 83 (B), hemoglobin 13.7 (C), and sodium 141 (D) are within normal limits.
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A 42-year-old female has thrombocytopenia with a platelet count of 75,000. The nurse should
- A. monitor for bleeding.
- B. place the client on neutropenic precautions.
- C. limit visiting hours.
- D. encourage a diet high in iron.
Correct Answer: A
Rationale: Thrombocytopenia (platelets <150,000) increases bleeding risk. Monitoring for bleeding (e.g., bruising, petechiae) is the priority.
The nurse is assisting a client who has experienced a left-sided cerebral vascular accident. The client requires assistance with personal hygiene. Which intervention should the nurse do initially?
- A. provide positive feedback
- B. place hygiene items on the client's left side
- C. provide assistive devices
- D. assess abilities and level of deficit
Correct Answer: D
Rationale: Assessing the client’s abilities and deficits first guides appropriate hygiene assistance, considering left-sided neglect or weakness.
The nurse is caring for a client diagnosed with C. diff. The client has soiled the bed and the nurse is preparing to change it. Which action by the nurse is correct in regard to handling soiled linens that have been exposed to C. diff?
- A. throw the linens in the trash can in the soiled utility room
- B. leave the dirty linens in a bag in the client's room until he is discharged
- C. place the items in a red biohazard bag and place them in the soiled utility room
- D. place the soiled linen in a regular dirty linen bag and place in the soiled utility room
Correct Answer: D
Rationale: C. diff-contaminated linens should be placed in a regular dirty linen bag, as they are processed with high-temperature washing to kill spores, not treated as biohazard waste.
The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority?
- A. Anxiety
- B. Pain
- C. Knowledge deficit
- D. Altered thought process
Correct Answer: C
Rationale: Knowledge deficit is a priority, as education on managing juvenile diabetes is critical for long-term health and compliance.
Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?
- A. Brushing the teeth
- B. Drinking a glass of juice
- C. Holding a cup of coffee
- D. Brushing the hair
Correct Answer: C
Rationale: Holding a warm cup of coffee can reduce morning stiffness in rheumatoid arthritis by providing warmth and gentle joint movement.