Nokea
A client with terminal cancer wishes to die at home. The nurse should:
- A. Arrange for home hospice services.
- B. Encourage hospitalization for better care.
- C. Advise against it due to lack of equipment.
- D. Inform the client it's not possible.
Correct Answer: A
Rationale: Arranging home hospice services supports the client's wish to die at home, providing necessary care and support in a comfortable environment.
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A male client who has been taking warfarin (Coumadin) has been admitted with severe acute rectal bleeding and the following laboratory results: International Normalized Ratio (INR), 8; hemoglobin, 11 g/dL; and hematocrit, 33%. Which of the following physician orders should the nurse expect to implement initially? Select all that apply.
- A. Administer I.V. dextrose 5% in 0.45% normal saline solution.
- B. Schedule client for a sigmoidoscopy in the morning.
- C. Give 1 unit fresh frozen plasma (FFP).
- D. Administer vitamin K (AquaMEPHYTON) 2.5 mg.
- E. Begin giving polyethylene glycol-electrolyte solution (GoLYTELY) in preparation for sigmoidoscopy.
- F. Administer Fleet enema.
Correct Answer: C,D
Rationale: An INR of 8 indicates excessive anticoagulation from warfarin, causing severe bleeding. Initial management includes administering fresh frozen plasma (FFP) to replace clotting factors and vitamin K to reverse warfarin's effects. Dextrose/saline, sigmoidoscopy preparation, and enemas are not immediate priorities.
What is the nurse's priority for a client with Guillain-Barré syndrome?
- A. Monitor respiratory function.
- B. Assess pain levels.
- C. Check skin integrity.
- D. Evaluate bowel function.
Correct Answer: A
Rationale: Monitoring respiratory function is the priority due to potential respiratory muscle weakness in Guillain-Barré syndrome.
A client has a history of heart failure and has been taking several medications, including furosemide (Lasix), digoxin (Lanoxin) and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. The nurse should assess the client for signs of which condition?
- A. Hyperkalemia.
- B. Digoxin toxicity.
- C. Fluid deficit.
- D. Pulmonary edema.
Correct Answer: B
Rationale: Nausea, blurred vision, confusion, and AV block are classic signs of digoxin toxicity, especially in a client taking digoxin, requiring immediate assessment.
The nurse evaluates that the client correctly understands how to report signs and symptoms of bleeding when the client makes which of the following statements?
- A. Petechiae are large, red skin bruises.'
- B. Ecchymoses are large, purple skin bruises.'
- C. Emmum is an open cut on the skin.'
- D. Abrasions are small pinpoint red dots on the skin.'
Correct Answer: B
Rationale: Ecchymoses are large, purple bruises caused by bleeding under the skin, a common sign of thrombocytopenia. This statement shows correct understanding. Petechiae are small, pinpoint red dots, not large bruises; 'emmum' is not a medical term; and abrasions are superficial skin injuries, not bleeding signs.
A client with leukemia is admitted with a white blood cell count of 2,000/mm³ and a fever of 101.8°F (38.8°C). The nurse should initiate:
- A. Contact precautions.
- B. Reverse isolation.
- C. Standard precautions.
- D. Droplet precautions.
Correct Answer: B
Rationale: A low white blood cell count (2,000/mm³) with fever indicates neutropenia and high infection risk, necessitating reverse isolation to protect the client from pathogens.