Nokea
A client undergoing chemotherapy has a white blood cell count of 2300/mm³; hemoglobin of 9.8 g/dL; platelet count of 80,000/mm³ and potassium of 3.8. Which of the following should take priority?
- A. Blood pressure 136/88.
- B. Emesis of 90 mL.
- C. Temperature 101°F (38.3°C).
- D. Urine output 40 mL/hour.
Correct Answer: C
Rationale: A fever of 101°F in a neutropenic client (WBC 2300/mm³) indicates a high risk of infection, which is a priority due to potential for rapid deterioration.
You may also like to solve these questions
A client on hemodialysis reports fatigue. The nurse should assess for:
- A. Anemia.
- B. Hyperkalemia.
- C. Dehydration.
- D. Infection.
Correct Answer: A
Rationale: Anemia is common in renal failure due to decreased erythropoietin.
Which of the following items of documentation is not required for the nurse to have on the chart before the client is transported to the operating suite?
- A. Operative consent.
- B. History and physical information.
- C. Laboratory test results.
- D. Anesthesia note.
Correct Answer: D
Rationale: The anesthesia note is completed intraoperatively or post-procedure by the anesthesiologist. The other documents are required preoperatively to ensure informed consent and medical readiness.
The nurse is preparing a preoperative teaching plan for a client who is undergoing a bilateral breast reduction. Which aspect of the plan is the priority?
- A. Reduction of risk potential.
- B. Physiologic adaptation.
- C. Psychosocial integrity.
- D. Health promotion and maintenance.
Correct Answer: C
Rationale: Psychosocial integrity is the priority for breast reduction surgery, as it addresses body image, self-esteem, and emotional adjustment, which are significant concerns for clients undergoing this procedure.
The nurse is caring for a client with a fractured pelvis in pelvic traction. Which activity is contraindicated?
- A. Log rolling to change positions.
- B. Deep breathing exercises.
- C. Using a trapeze for repositioning.
- D. Applying moisturizer to the skin.
Correct Answer: A
Rationale: Log rolling is contraindicated in pelvic traction to maintain alignment and prevent displacement.
The nurse provides discharge instructions to a client diagnosed with bacterial conjunctivitis. Which of the following statements by the client would indicate effective understanding? Select all that apply.
- A. It is okay for me to wear my contact lenses during this infection.'
- B. Swimming during this infection is allowed.'
- C. I should not share my towels with family members.'
- D. To prevent injury, I should not rub my eye.'
- E. I should wash my hands frequently.'
Correct Answer: C,D,E
Rationale: Bacterial conjunctivitis requires avoiding contact lenses and swimming to prevent worsening or spreading infection, not sharing towels, avoiding eye rubbing to prevent corneal damage, and frequent hand washing to reduce transmission.