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. Hgb level increase from 8.9 to 10.6
- B. Temperature reading of 99.4°F
- C. White blood cell count of 11,000
- D. Decrease in oozing of blood from IV site
Correct Answer: D
Rationale: Platelet infusions aim to improve clotting. Decreased oozing from an IV site indicates effective platelet function. The other findings are unrelated to platelets.
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A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain?
- A. The pain will go away in a few days.
- B. The pain is due to peripheral nervous system interruptions. I will get you some pain medication.
- C. The pain is psychological because your foot is no longer there.
- D. The pain and itching are due to the infection you had before the surgery.
Correct Answer: B
Rationale: Phantom limb pain results from peripheral nervous system interruptions, and offering pain medication addresses the client's discomfort appropriately.
A 6-year-old with cerebral palsy functions at the level of an 18-month-old. Which finding would support that assessment?
- A. She dresses herself.
- B. She pulls a toy behind her.
- C. She can build a tower of eight blocks.
- D. She can copy a horizontal or vertical line.
Correct Answer: B
Rationale: Pulling a toy is consistent with an 18-month-old's developmental level, supporting the assessment.
A client with rheumatoid arthritis tells the nurse that she is having increasing difficulty cooking, cleaning, and attending to activities of daily living. Which of the following referrals is the most appropriate?
- A. Occupational therapist.
- B. Physical therapist.
- C. Home health agency.
- D. Assisted-living facility.
Correct Answer: A
Rationale: An occupational therapist (A) helps clients with rheumatoid arthritis adapt to difficulties with daily activities through adaptive techniques and equipment. Physical therapy (B), home health (C), or assisted living (D) may be secondary.
A non-immune nurse should not be assigned a client who has which of the vaccine-preventable airborne diseases? Select all that apply.
- A. tuberculosis
- B. influenza
- C. smallpox
- D. pertussis
Correct Answer: A,C
Rationale: Tuberculosis and smallpox are airborne, vaccine-preventable diseases posing risks to non-immune nurses. Influenza and pertussis are primarily droplet-transmitted.
A 9-year-old child weighing 40 kilograms has an order for piperacillin (Pipracil) via IV infusion. The recommended daily dose for this medication is 240-300 mg/kg/day IV div. q8h. What is the maximum daily dose of piperacillin this client can receive per day? Calculate and fill in the blank.
Correct Answer: 12,000 mg
Rationale: Maximum dose: 300 mg/kg/day × 40 kg = 12,000 mg/day.