Nokea
A client receiving chemotherapy has a platelet count of 15,000 mm³ (15 x 10â¹/L). Based on this laboratory result, which form of precautions should the nurse implement?
- A. Contact
- B. Bleeding
- C. Respiratory
- D. Neutropenic
Correct Answer: B
Rationale: When the platelet count is less than 20,000 mm³ (20 x 10â¹/L), the client is at risk for bleeding, and the nurse should institute bleeding precautions. Contact precautions are initiated in a client who has drainage from wounds that may be infectious. Respiratory precautions are instituted for a client with a respiratory infection that is transmitted by the airborne route. Neutropenic precautions would be instituted for a client with a low neutrophil count.
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A 38-year-old client with a history of type 1 diabetes mellitus is admitted with an infected foot ulcer. The nurse should recognize that wound healing may be delayed because of:
- A. Increased tissue perfusion.
- B. Impaired collagen synthesis.
- C. Enhanced immune response.
- D. Increased fibroblast activity.
Correct Answer: B
Rationale: In diabetes, impaired collagen synthesis due to poor glycemic control delays wound healing, increasing infection risk.
Which of the following compensatory actions by the body would occur if a client were in respiratory acidosis?
- A. Excretion of bicarbonate (HCO₃⁻) by the kidneys.
- B. Retention of HCO₃⁻ by the kidneys.
- C. Increase in respiratory rate by the lungs.
- D. Decrease in respiratory rate by the lungs.
Correct Answer: B, C
Rationale: In respiratory acidosis, the body compensates by retaining bicarbonate (HCO₃⁻) in the kidneys and increasing respiratory rate to eliminate excess CO2.
The nurse is caring for a child with sickle cell anemia who is experiencing a vaso-occlusive crisis. Which of the following interventions is the priority?
- A. Administer oxygen.
- B. Provide hydration.
- C. Apply warm compresses.
- D. Administer analgesics.
Correct Answer: B
Rationale: Hydration is the priority in vaso-occlusive crisis to reduce blood viscosity and promote circulation, preventing further sickling and complications.
The nurse is teaching a client with a new tracheostomy about home care. Which of the following instructions should be included? Select all that apply.
- A. Clean the tracheostomy site daily.
- B. Suction the tracheostomy as needed.
- C. Change the tracheostomy tube monthly.
- D. Keep a spare tracheostomy tube at home.
- E. Use a humidifier to keep secretions thin.
Correct Answer: A, B, D, E
Rationale: Daily cleaning, suctioning, keeping a spare tube, and using a humidifier are essential for tracheostomy care. Tube changes are typically done by professionals.
The nurse is preparing to insert a urinary catheter. Which action ensures sterile technique?
- A. Cleanse the meatus with an alcohol swab
- B. Use clean gloves during insertion
- C. Apply sterile lubricant to the catheter tip
- D. Insert the catheter without a drape
Correct Answer: C
Rationale: Applying sterile lubricant to the catheter tip maintains sterile technique, reducing the risk of infection during urinary catheter insertion.