Nokea
A client with neutropenia is at risk for sepsis. Which of the following is the earliest sign the nurse should monitor for?
- A. Hypotension.
- B. Tachycardia.
- C. Oliguria.
- D. Confusion.
Correct Answer: B
Rationale: Tachycardia is often the earliest sign of sepsis, reflecting the body's response to infection, and requires prompt monitoring in a neutropenic client.
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The physician orders Morphine Sulfate 2-4 mg IV push every 2 hours prn pain for a client who has postoperative pain following abdominal surgery. Prior to performing an abdominal dressing change with packing at 10 AM, the nurse assesses the client's pain level as 1 on a scale of 0 = no pain to 10 = the worst pain. The client is awake and oriented and vital signs are within normal limits. The nurse reviews the pain medication record (see chart). The nurse should:
- A. Perform the dressing change.
- B. Administer Morphine 2 mg IV before the dressing change.
- C. Administer Morphine 4 mg IV after the dressing change.
- D. Call the physician for a new medication order.
Correct Answer: A
Rationale: With a pain level of 1, the client does not require morphine (prn order). Performing the dressing change is appropriate, as the pain is minimal and manageable.
A nurse receives the taped change-of-shift report for assigned clients and prioritizes client rounds. In what order should the nurse assess these clients?
- A. A client with an endotracheal tube transferred out of the intensive care unit that day.
- B. A client with type 2 diabetes who had a cerebrovascular accident 4 days ago.
- C. A client with cellulitis of the left lower extremity with a fever of 100.8°F (38.2°C).
- D. A client receiving D5W I.V. at 125 mL/hour with 75 mL remaining.
Correct Answer: A,C,B,D
Rationale: The client with a new endotracheal tube (A) is highest priority due to airway risk. The febrile client with cellulitis (C) is next for infection monitoring. The stroke client (B) is stable 4 days post-event. The I.V. fluid client (D) is lowest priority.
On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for:
- A. Limited motion of joints.
- B. Deformed joints of the hands.
- C. Early morning stiffness.
- D. Rheumatoid nodules.
Correct Answer: C
Rationale: Early morning stiffness is a hallmark symptom of rheumatoid arthritis, especially in the early stages, as it reflects joint inflammation that worsens after periods of inactivity.
A client with neutropenia has an absolute neutrophil count of 900. What is the client's risk of infection?
- A. Normal risk.
- B. Moderate risk.
- C. High risk.
- D. Extremely high risk.
Correct Answer: C
Rationale: An absolute neutrophil count (ANC) of 900 indicates moderate to severe neutropenia (ANC <1,000). This places the client at high risk for infection, as neutrophils are critical for fighting pathogens. Normal risk is ANC >1,500, and extremely high risk is ANC <200.
A client is to be discharged with a prescription for lactulose (Cephulac). The nurse teaches the client and the client's spouse how to administer this medication. Which of the following statements would indicate that the client has understood the information?
- A. I'll take it with Maalox.'
- B. I'll mix it with apple juice.'
- C. I'll take it with a laxative.'
- D. I'll mix the crushed tablets in some gelatin.'
Correct Answer: B
Rationale: Mixing lactulose with apple juice (B) improves palatability. Maalox (A) is unrelated, additional laxatives (C) are unnecessary, and lactulose is a liquid, not a tablet (D).