Nokea
A client with pernicious anemia is admitted. What would the nurse expect the admitting assessment to reveal?
- A. Ecchymoses on the trunk
- B. Bilateral neuropathy of the legs
- C. Decreased platelet count
- D. Decreased appetite
Correct Answer: B
Rationale: Pernicious anemia, a vitamin B12 deficiency, often causes neurological symptoms like bilateral leg neuropathy due to nerve demyelination.
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A nurse performing actions that would be considered negligence.
Which of the following actions, if performed by the nurse, would be considered negligence?
- A. The nurse performs range-of-motion (ROM) exercises for a client with second- and third-degree burns of the chest.
- B. The nurse sits with a client who suffers from depression while he eats his lunch.
- C. The nurse caring for a client with myasthenia gravis administers the 7 AM dose of neostigmine bromide (Prostigmin) PO at 7:45 AM.
- D. The nurse instructs a 15-year-old girl who is sexually active about different types of contraceptives without consulting her parents.
Correct Answer: C
Rationale: Strategy: 'Negligence' indicates an incorrect action. (1) minimizes muscle atrophy (2) promotes eating, offer more frequent feedings of favorite foods (3) correct-delay in medication may cause difficulty in swallowing, might have difficulty taking medication (4) minor can request birth control without the parent's consent
The nurse is teaching a client with chronic kidney disease about dietary restrictions. Which of the following foods should the nurse advise the client to limit?
- A. Fresh strawberries.
- B. Baked chicken.
- C. Potato chips.
- D. Brown rice.
Correct Answer: C
Rationale: Potato chips are high in sodium and potassium, which must be limited in chronic kidney disease to prevent fluid retention and hyperkalemia. Options A, B, and D are more suitable: strawberries are low-potassium, chicken is protein-rich, and brown rice is acceptable in moderation.
A client is admitted with renal calculi and is experiencing severe pain. Meperidine (Demerol) 75 mg IM is given prior to the change of shift.
Which of the following symptoms is MOST important for the nurse to report to the next shift?
- A. Nausea with a small amount of vomitus.
- B. Pain of five on a scale of one to ten.
- C. Change in the location and character of pain.
- D. No known drug allergies.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to renal calculi. (1) often accompanies pain, but is not most important to report to next shift (2) important, but not the highest priority (3) correct-location of the pain depends on location of renal stone; character of pain changes depending on location or movement of stone (4) important, but not the highest priority
The nurse is caring for a client who is postoperative day 1 after a lumbar laminectomy. Which of the following actions is the PRIORITY?
- A. Encourage the client to log-roll when turning.
- B. Administer pain medication as needed.
- C. Monitor the surgical drain for output.
- D. Check the incision for redness.
Correct Answer: A
Rationale: Encouraging log-rolling is the priority to prevent spinal strain and maintain alignment post-lumbar laminectomy. Options B, C, and D are important but secondary: pain management, drain monitoring, and incision checks follow proper positioning.
The client who is scheduled for a knee replacement asks the nurse why she should donate her own blood before surgery. How should the nurse respond?
- A. The blood bank is very short of blood.'
- B. Your own blood is the correct type for you.'
- C. It eliminates the chance of blood-borne diseases such as hepatitis and HIV.'
- D. Your own blood increases your energy level after surgery.'
Correct Answer: C
Rationale: Autologous blood donation eliminates transfusion-related infection risks, like hepatitis or HIV, ensuring safety during surgery.