Nokea
A client with cancer received platelet infusions 24 hours ago. Which of the following assessment findings would indicate the most therapeutic effect from the transfusions?
- A. An Hgb level decrease from 8.9 to 8.7
- B. A temperature reading of 99.4
- C. A white blood cell count of 11,000
- D. A decrease in oozing of blood from the IV site
Correct Answer: D
Rationale: Platelets deal with the clotting of blood. Lack of platelets can cause bleeding. Answers A, B, and C do not directly relate to platelets, so they are incorrect.
You may also like to solve these questions
The nurse is caring for a client with oral candidiasis who has a new prescription for nystatin oral suspension. Which of the following actions should the nurse take? Select all that apply.
- A. Tell the client to avoid eating or drinking for at least 30 minutes after taking nystatin.
- B. Monitor the client's oral mucous membranes for redness, swelling, and irritation.
- C. Remind the client to discontinue the nystatin once the symptoms subside.
- D. Shake the bottle of nystatin thoroughly before measuring the dose.
- E. Instruct the client to swish the nystatin around the mouth.
Correct Answer: A,B,D,E
Rationale: For nystatin oral suspension: avoid eating/drinking for 30 minutes to ensure contact time; monitor oral membranes for treatment response; shake the bottle for proper dosing; and swish in the mouth for efficacy. Discontinuing early risks recurrence.
An adult comes to the clinic with complaints of frequency and burning on urination. The nurse expects that what test will be ordered for the client?
- A. Clean catch urine for culture and sensitivity
- B. CBC and electrolytes
- C. Cystoscopy
- D. Strain of all urine for calculi
Correct Answer: A
Rationale: Frequency and burning suggest urinary tract infection; a clean catch urine culture identifies the causative organism and antibiotic sensitivity. CBC, cystoscopy, or straining are less immediate.
The nurse is caring for a client who has a prescription for clarithromycin 7.5 mg/kg/day PO in 2 divided doses. The client weighs 78 lb. How many mL should the nurse administer for each dose? Record your answer using 1 decimal place.
Correct Answer: 7.5 mL/dose
Rationale: Client weight: 78 lb ÷ 2.2 = 35.45 kg. Dose: 7.5 mg/kg/day × 35.45 kg = 265.875 mg/day ÷ 2 doses = 132.9375 mg/dose. Clarithromycin is typically 250 mg/5 mL. Thus, 132.9375 mg × (5 mL/250 mg) = 2.65875 mL ≈ 2.7 mL/dose.
The nurse is caring for a client who is terminally ill. When the client dies, the nurse should:
- A. Pronounce the client dead and call the doctor.
- B. Contact the coroner.
- C. Tag the body prior to the funeral home notification.
- D. Request an autopsy.
Correct Answer: C
Rationale: Tagging the body ensures proper identification before transfer to the funeral home. Nurses do not pronounce death, coroner contact depends on policy, and autopsies are not routinely requested.
A client receiving total parenteral nutrition reports nausea, abdominal pain, and excessive thirst. What is the best action for the nurse to take?
- A. Check the client's blood glucose
- B. Check the client's vital signs
- C. Report the findings to the health care provider
- D. Slow down the rate of infusion
Correct Answer: A
Rationale: Nausea, abdominal pain, and thirst in a TPN client suggest hyperglycemia, so checking blood glucose is the best action. Vital signs , reporting , or slowing infusion are secondary without glucose confirmation.