Nokea
A client with acute leukemia develops a low white blood cell count. In addition to the institution of isolation, the nurse should:
- A. Request that foods be provided in sealed single-serving packages
- B. Ask the client to wear a mask when visitors are present
- C. Prep IV sites with mild soap and water and alcohol
- D. Provide foods in sealed single-serving packages
Correct Answer: D
Rationale: For a client with acute leukemia and a low white blood cell count, preventing exposure to food contaminants is crucial due to immune suppression. Providing foods in sealed single-serving packages helps reduce the risk of contamination. Choice B is incorrect as it introduces the potential of infection from visitors. Choice A, suggesting disposable utensils, is not as effective as sealed containers in preventing food contamination. Choice C, using alcohol for prepping IV sites, is less suitable due to its drying effect and potential for skin breakdown, making sealed packages a better option for food safety.
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What should the charge nurse do after overhearing the patient care assistant speaking harshly to the client with dementia?
- A. Change the patient care assistant's assignment
- B. Explore the interaction with the patient care assistant
- C. Discuss the matter with the client's family
- D. Initiate a group session with the patient care assistant
Correct Answer: B
Rationale: The best action for the charge nurse to take is to explore the interaction with the patient care assistant. This step allows for clarification of the situation and direct addressing of the issue. Changing the patient care assistant's assignment (choice A) might be necessary, but understanding the situation should come first. Discussing the matter with the client's family (choice C) as an initial step could escalate the situation. Initiating a group session with the patient care assistant (choice D) could be considered later as a preventive measure to avoid similar incidents in the future.
During discharge teaching for a client with diverticulitis on a low-roughage diet, which food should be eliminated from the diet?
- A. Roasted chicken
- B. Noodles
- C. Cooked broccoli
- D. Custard
Correct Answer: C
Rationale: The client with diverticulitis needs to avoid gas-forming foods that can increase abdominal discomfort. Cooked broccoli is a high-fiber food that can worsen symptoms. Roasted chicken, noodles, and custard are suitable choices for a low-roughage diet as they are less likely to cause gas formation or abdominal discomfort.
A client has been taking alprazolam (Xanax) for four years to manage anxiety. The client reports taking 0.5 mg four times a day. Which statement indicates that the client understands the nurse's teaching about discontinuing the medication?
- A. "I can drink alcohol now that I am decreasing my Xanax."?
- B. "I should not take another Xanax pill. Here is what is left of my last prescription."?
- C. "I should take three pills per day next week, then two pills for one week, then one pill for one week."?
- D. "I can expect to be sleepy for several days after stopping the medicine."?
Correct Answer: C
Rationale: Explanation: When discontinuing alprazolam (Xanax) after long-term use, it is crucial to taper the dosage gradually to prevent withdrawal symptoms. The correct statement indicates an understanding of this by planning a structured decrease in dosage over time. Choice A is incorrect as drinking alcohol while decreasing Xanax can be dangerous and is not recommended. Choice B is incorrect as abruptly stopping Xanax is not safe and can lead to withdrawal symptoms. Choice D is incorrect as expecting to be sleepy for several days after stopping the medication does not address the need for a gradual tapering process to avoid withdrawal symptoms.
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
- A. Continue monitoring the vital signs
- B. Contact the physician
- C. Ask the client how they feel
- D. Ask the LPN to continue post-op care
Correct Answer: B
Rationale: The priority action for the nurse is to contact the physician immediately due to the client's abnormal vital signs. A blood pressure of 90/50, pulse of 132, and respirations of 30 indicate instability and require prompt medical attention. Continuing to monitor vital signs, as in choice A, may lead to a delay in necessary interventions. Asking the client how they feel, as in choice C, provides subjective data and does not address the urgent need for medical intervention. Involving the LPN, as in choice D, is not appropriate in this critical situation where the client's condition is unstable and requires immediate physician assessment and intervention.
An infant weighs 7 pounds at birth. What is the expected weight by 1 year of age?
- A. 10 pounds
- B. 12 pounds
- C. 18 pounds
- D. 21 pounds
Correct Answer: D
Rationale: A birth weight of 7 pounds typically triples by the age of 1 year, resulting in an expected weight of 21 pounds. This significant weight gain is a normal growth pattern for infants as they usually experience rapid growth in the first year of life. Choices A, B, and C are incorrect because they do not account for the usual growth rate of an infant in the first year. Infants commonly triple their birth weight by the age of 1, making 21 pounds the expected weight.