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A client on chemotherapy has a WBC count of 1,200/mm^3. Which of the following nursing actions should the nurse take FIRST?
- A. Check temperature q 4 h.
- B. Monitor urine output.
- C. Assess for bleeding gums.
- D. Obtain an order for blood cultures.
Correct Answer: A
Rationale: A WBC count of 1,200/mm^3 indicates severe neutropenia, increasing infection risk. Checking temperature every 4 hours detects fever early, a priority. Options B, C, and D are secondary: urine output is unrelated, bleeding gums suggest thrombocytopenia, and blood cultures require fever.
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The nurse is teaching a client with a new diagnosis of type 1 diabetes about insulin glargine (Lantus). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this insulin at bedtime.
- B. I should not mix this insulin with other insulins.
- C. I should rotate injection sites.
- D. I should take this insulin when my blood sugar is high.
Correct Answer: D
Rationale: Taking insulin glargine when blood sugar is high is incorrect, as it is a long-acting basal insulin for steady control, not for acute hyperglycemia. Options A, B, and C are correct: bedtime dosing is standard, it should not be mixed, and rotation prevents lipodystrophy.
Which of the following describes the proximodistal development in the infant?
- A. The infant is able to raise his head before he is able to sit.
- B. The infant can control movements of his arms before he can control movements of his fingers.
- C. The infant responds to pain with his whole body before he can localize pain.
- D. The infant is able to make rudimentary vocalizations before using spoken words.
Correct Answer: B
Rationale: Proximodistal development refers to motor control progressing from the center of the body outward, meaning infants gain control of larger muscles (arms) before finer muscles (fingers).
A 48-year-old woman is seen in the outpatient clinic for complaints of irregular menses.
- A. What is the most probable cause of irregular menses in a 48-year-old woman with a history of regular periods?
- B. Emotional trauma and stress.
- C. The onset of menopause.
- D. The presence of uterine fibroids.
- E. A possible tubal pregnancy.
Correct Answer: B
Rationale: Irregular menses in a 48-year-old woman is most likely due to menopause, as ovarian function declines between ages 45- Stress lacks supporting data, fibroids cause excessive bleeding, and tubal pregnancy typically presents with missed periods and pain.
Which of these clients would the triage nurse request the provider examine immediately?
- A. A 5 month-old infant who has audible wheezing and grunting
- B. An adolescent who has soot over the face and shirt
- C. A middle-aged man with second degree burns over the right hand
- D. A toddler with singed ends of long hair that extends to the waist
Correct Answer: A
Rationale: A 5 month-old infant who has audible wheezing and grunting. The age and the findings suggest this client is at immediate risk for respiratory complications.
A child admitted with failure to thrive has just had a positive sweat Test .
The nurse would anticipate which of the following changes in the child's plan of care initially?
- A. Administration of replacement enzymes.
- B. Administration of oxygen.
- C. A salt-restricted diet.
- D. Initiate intravenous therapy.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-sweat Test is a positive finding for cystic fibrosis (2) no data in this situation to indicate that the child is having pulmonary problems (3) salt is increased in diet (4) no need for IV therapy based on the data in situation