Nokea
A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale, and febrile. After reviewing the client's most recent laboratory data which reveals a platelet count of 25,000/mm3 (25 x 109/L), which intervention should the nurse include in the plan of care?
- A. Ensure a large gauge IV catheter is used to obtain blood samples.
- B. Monitor urine and stool for occult blood regularly.
- C. Remove cold and frozen foods from dietary trays.
- D. Wrap bruised areas with elastic bandage dressings.
Correct Answer: B
Rationale: Monitoring for occult blood is critical with severe thrombocytopenia to detect internal bleeding early, preventing life-threatening complications.
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The nurse is caring for a client after a coronary artery bypass graft surgery. The client is exhibiting pitting edema of the lower extremities and jugular venous distention with increased central venous pressure. Which condition should the nurse suspect the client is experiencing based on these findings?
- A. Right-sided heart failure.
- B. Left ventricular dysfunction.
- C. Cardiac tamponade.
- D. Internal bleeding.
Correct Answer: A
Rationale: Right-sided heart failure causes systemic venous congestion, leading to edema, jugular distention, and elevated central venous pressure.
A client receives a prescription for 1 L of lactated Ringers to be infused IV over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)
- A. 125 mL/hr
Correct Answer: A
Rationale: Calculation: 1000 mL ÷ 8 hours = 125 mL/hr, ensuring accurate infusion rate.
A client reports to the clinic nurse of recently experiencing symptoms of frequent urination, hunger, and great thirst. What finding(s) would the nurse consider as most significant to report to the healthcare provider? Select all that apply.
- A. Total cholesterol 180 mg/dL (4.7 mmol/L).
- B. Hematocrit 45% (0.45 volume fraction).
- C. Random plasma glucose level 200 mg/dL (11.1 mmol/L).
- D. Hemoglobin A1C 7%.
- E. Serum potassium of 4.2 mEq/L (4.2 mmol/L).
Correct Answer: C,D
Rationale: Elevated glucose and HbA1C indicate diabetes, correlating with the client's symptoms and requiring urgent management.
The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which Instruction regarding skin care of the portal site should the nurse provide?
- A. Remove the ink marks of the portal after each radiation treatment.
- B. Protect the skin of the radiation portal site from sunlight exposure.
- C. Apply moisture lotions daily to the radiation portal site.
- D. Avoid washing the skin inside the radiation portal site.
Correct Answer: B
Rationale: Protecting the portal site from sunlight prevents exacerbated skin reactions during radiation therapy.
History and Physical Nurses' Notes
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
Based on the client's history and assessment data, the nurse's hypothesis is that the client's vital signs are most likely the result of disease process, medication use, or neither. Each column must have at least one, but may have more than one answer selected.
- A. Blood pressure 130/86 mmHg
- B. Respirations 28 breaths/minute
- C. Temperature 98.9" F (37.1°C)
- D. Heart rate 112 beats/minute
- E. Oxygen saturation 88% on room air
Correct Answer: A,B
Rationale: Tachypnea results from bronchospasm in asthma, impairing ventilation. Elevated heart rate is a side effect of beta-agonist inhalers used during the attack.