Nokea
A client with a history of a bone marrow transplant is receiving immunosuppressive therapy. The nurse should monitor the client for:
- A. Infection
- B. Hypotension
- C. Hyperglycemia
- D. Hair loss
Correct Answer: A
Rationale: Immunosuppressive therapy post-bone marrow transplant increases infection risk due to suppressed immunity. Hypotension, hyperglycemia, and hair loss are less immediate concerns.
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A client with a history of chronic migraines is admitted with complaints of headache. The nurse should give priority to:
- A. Administering analgesics
- B. Monitoring blood pressure
- C. Providing a quiet environment
- D. Administering oxygen
Correct Answer: C
Rationale: A quiet environment reduces sensory stimuli, which can exacerbate migraines, making it a priority to promote comfort.
The client is admitted with a diagnosis of chorioamnionitis. Which vital sign change is most likely to be observed?
- A. Maternal fever
- B. Tachycardia
- C. Fetal bradycardia
- D. All of the above
Correct Answer: D
Rationale: Chorioamnionitis causes maternal fever (from infection) tachycardia (from systemic response) and fetal bradycardia (from distress). All vital sign changes are likely in this condition.
The client is prescribed warfarin (Coumadin). Which food should the nurse instruct the client to limit?
- A. Spinach
- B. Apples
- C. Chicken
- D. Rice
Correct Answer: A
Rationale: Spinach is high in vitamin K, which antagonizes warfarin’s anticoagulant effect, potentially reducing its efficacy. Apples, chicken, and rice have negligible vitamin K.
A long-term goal for the nurse in planning care for a depressed, suicidal client would be to:
- A. Provide him with a safe and structured environment.
- B. Assist him to develop more effective coping mechanisms.
- C. Have him sign a 'no-suicide' contract.
- D. Isolate him from stressful situations that may precipitate a depressive episode.
Correct Answer: B
Rationale: This statement represents a short-term goal. Long-term therapy should be directed toward assisting the client to cope effectively with stress. Suicide contracts represent short-term interventions. This statement represents an unrealistic goal. Stressful situations cannot be avoided in reality.
A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:
- A. Assess the site for leakage of blood or fluids
- B. Auscultate the site for a bruit
- C. Assess the site for bruising or hematoma
- D. Inspect the site for color, warmth, and sensation
Correct Answer: B
Rationale: This is an internal device. Assessment of the site should include assessing for swelling, pain, warmth, and discoloration. This measure does not assess patency. The presence of a bruit indicates good blood flow through the device. The nurse should inspect the site for bruising or hematoma; however, this measure does not assure patency of the device. The nurse should inspect the vascular access site frequently for signs of infection. However, this does not assure patency.