Nokea
A client with chemotherapy-induced thrombocytopenia has a platelet count of 18,000/mm³. Which nursing intervention is most important?
- A. Administer aspirin for pain.
- B. Monitor for signs of bleeding.
- C. Encourage vigorous oral hygiene.
- D. Restrict visitors.
Correct Answer: B
Rationale: A platelet count of 18,000/mm³ indicates severe thrombocytopenia, making monitoring for bleeding (e.g., petechiae, epistaxis) the most important intervention to prevent complications.
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After cataract removal surgery, the client is instructed to report sharp pain in the operative eye because this could indicate which of the following postoperative complications?
- A. Detached retina.
- B. Prolapse of the iris.
- C. Extracapsular erosion.
- D. Intraocular hemorrhage.
Correct Answer: D
Rationale: Sharp pain in the operative eye post-cataract surgery may indicate intraocular hemorrhage, which can increase intraocular pressure and cause severe pain, requiring immediate intervention.
The most appropriate suggestion for the hospice nurse to give a woman whose husband died 3 months ago and her three young children would be to:
- A. Seek group counseling support for the three children.
- B. Request individual counseling and medication to manage depression.
- C. Remind her gently that bereavement care before the child's effective grieving.
- D. Continue her bereavement support through hospice.
Correct Answer: D
Rationale: Continuing bereavement support through hospice provides ongoing emotional support for the woman and her children, tailored to their needs during grief.
The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that:
- A. There is a strong link between alcohol use and acute pancreatitis.
- B. Alcohol intake can interfere with the tests used to diagnose pancreatitis.
- C. Alcoholism is a major health problem, and all clients are questioned about alcohol intake.
- D. The physician must obtain the pertinent facts, regardless of religious beliefs.
Correct Answer: A
Rationale: Alcohol is a primary cause of acute pancreatitis, so questioning its use (A) is essential to identify etiology. Interference with tests (B), general alcoholism screening (C), or disregarding beliefs (D) are not accurate explanations.
The nurse should teach the neutropenic client and the family to avoid which of the following?
- A. Using suppositories or enemas.
- B. Using a high-efficiency particulate air (HEPA) filter mask.
- C. Performing perianal care after every bowel movement.
- D. Performing oral care after every meal.
Correct Answer: A
Rationale: Neutropenic clients should avoid suppositories or enemas, as they can cause rectal trauma and introduce infections. HEPA masks, perianal care, and oral care are recommended to reduce infection risk.
Allopurinol (Zyloprim), 200 mg/day, is prescribed for the client with renal calculi to take at home. The nurse should teach the client about which the following adverse effects of this medication?
- A. Retinopathy.
- B. Maculopapular rash.
- C. Nasal congestion.
- D. Dizziness.
Correct Answer: B
Rationale: Maculopapular rash is a common adverse effect of allopurinol, requiring monitoring due to potential allergic reactions.