Nokea
A client states, 'I don't want any more tests. Who cares what kind of leukemia I have? I just want to be treated now.' Which is the nurse's best response?
- A. I'm sure you are frustrated and want to be well now.'
- B. Your treatment can be more effective if it is based on more specific information about your disease.'
- C. Now, you know the tests are necessary and that you are just upset right now.'
- D. I understand how you feel.'
Correct Answer: B
Rationale: The nurse should explain that specific tests help tailor treatment to the type of leukemia, improving effectiveness. This addresses the client's desire for treatment while emphasizing the importance of diagnostic clarity. The other responses are empathetic but do not provide a rationale for testing.
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Which intervention is most effective for a client with MS-related vision impairment?
- A. Provide bright lighting.
- B. Use large-print materials.
- C. Limit visual activities.
- D. Wear dark glasses.
Correct Answer: B
Rationale: Large-print materials support clients with MS-related vision impairment by improving readability.
A male client with a head injury regains consciousness and the normal loss. Which of the following nursing statements is most appropriate as the client awakens?
- A. I'll get your family.
- B. Can you tell me your name and where you live?
- C. I'll bet you're a little confused right now.
- D. You are in the hospital. You were in an accident and unconscious.
Correct Answer: D
Rationale: Providing clear, concise orientation information is most appropriate for a client regaining consciousness to reduce confusion and anxiety. Calling family, asking for personal details, or assuming confusion may overwhelm or distress the client.
Which is a priority assessment for the client in shock who is receiving an I.V. infusion of packed red blood cells and normal saline solution?
- A. Fluid balance.
- B. Anaphylactic reaction.
- C. Pain.
- D. Altered level of consciousness.
Correct Answer: B
Rationale: During a blood transfusion in a client in shock, the priority assessment is for an anaphylactic reaction, as transfusion reactions can be life-threatening and require immediate intervention. Fluid balance, pain, and consciousness are monitored but are secondary.
Which of the following adverse effects would the nurse expect the client to exhibit in the event of too rapid an infusion of TPN solution?
- A. Negative nitrogen balance.
- B. Circulatory overload.
- C. Hypoglycemia.
- D. Hypokalemia.
Correct Answer: B
Rationale: Too rapid an infusion of TPN can cause circulatory overload due to the high volume and osmolarity of the solution. Negative nitrogen balance, hypoglycemia, or hypokalemia are not directly caused by rapid infusion. CN: Pharmacological and parenteral therapies; CL: Analyze
Which of the following complications is associated with mechanical ventilation?
- A. Gastrointestinal hemorrhage.
- B. Immunosuppression.
- C. Increased cardiac output.
- D. Pulmonary emboli.
Correct Answer: D
Rationale: Mechanical ventilation increases the risk of pulmonary emboli due to immobility and hypercoagulability. Gastrointestinal hemorrhage, immunosuppression, and increased cardiac output are less directly related.