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, 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. Wrap bruised areas with elastic bandage dressings.
- C. Remove cold and frozen foods from dietary trays.
- D. Monitor urine and stool for occult blood regularly.
Correct Answer: D
Rationale: Monitoring urine and stool for occult blood is crucial for thrombocytopenic patients at increased risk of bleeding, allowing early detection and management.
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The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?
- A. Collect the blood sample.
- B. Select another finger.
- C. Apply pressure to the site.
- D. Assess radial pulse volume.
Correct Answer: B
Rationale: Selecting another finger ensures an accurate blood sample and minimizes discomfort, as a reddened and engorged fingertip may lead to inaccurate readings.
The nurse assists a client with Parkinson's disease to ambulate in the hallway. The client appears to 'freeze' and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?
- A. Plan to assess the client's cognition after returning to the room.
- B. Confirm that this is an effective technique to help with ambulation.
- C. Assist the client to a carpeted area to walk more easily.
- D. Reorient the client to the present location and circumstances.
Correct Answer: B
Rationale: Confirming that the client's technique of pretending to step over a crack is an effective strategy acknowledges the client's self-initiated coping mechanism for freezing episodes, which can help promote independence in ambulation.
History and Physical
Nurses' Notes
Flow Sheet
Laboratory Results
The nurse is caring for a client who was admitted to the hospital with reports of shortness of breath, fever, fatigue, and oral thrush three days ago. The health care provider reviews the laboratory and diagnostic tests with the client and informs of the diagnosis of Pneumocystis pneumonia. The client reports that they recently tested HIV positive. The nurse reviews the client's medical record.
HIV diagnosed 4 months ago with no medications prescribed.
Note added to H&P reporting client wishes to be confidential since family and friends are unaware of the HIV diagnosis.
What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.
- A. Increase IV fluids to 150 mL/hr
- B. Monitor for adverse reaction to antibiotics
- C. Repeat CD4+ T-cell count STAT
- D. Initiate airborne isolation
- E. Administer antiemetic
Correct Answer: A,B,E
Rationale: Increasing IV fluids, monitoring for antibiotic reactions, and administering an antiemetic address the client's fever, potential infection, and nausea associated with Pneumocystis pneumonia.
A client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?
- A. Wear braces on both wrists during the night.
- B. Notify the healthcare provider as soon as possible.
- C. Elevate the hands on two pillows at night.
- D. Apply cold compresses for 30 minutes before bedtime.
Correct Answer: A
Rationale: Wearing braces on both wrists during the night can help maintain a neutral wrist position and alleviate pressure on the median nerve, reducing symptoms of carpal tunnel syndrome.
History and Physical Nurses' Notes
Flow Sheet
A 59-year-old male client presents to the clinic reporting pain in the right great toe. The client says that the pain feels like it is another attack of gout, which he has had on 2 other occasions in the last 4 months.
The client tells the nurses that the pain started about 9 days ago in the evening and that it got very painful and swollen shortly thereafter. In the past, the gout attacks have resolved without treatment after about 5 days, but the client reports that his condition has not
Which finding(s) in the client's health record should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.
- A. Obesity
- B. Hypertension
- C. Drinks beer nightly
- D. Daily aspirin
- E. Type 2 diabetes mellitus
- F. Sleep apnea
- G. Ibuprofen for pain
Correct Answer: A,B,C,D,E,F
Rationale: Obesity, hypertension, alcohol consumption (especially beer), low-dose aspirin, type 2 diabetes mellitus, and sleep apnea are all associated with increased uric acid levels or decreased excretion, contributing to gout risk. Ibuprofen, smoking status, and osteoarthritis do not directly increase gout risk.