Nokea
A client with the diagnosis of leukemia is receiving chemotherapy. When the registered nurse (RN) notes that the white blood cell (WBC) count is 4000 mm^3 (4 x 10^9/L), the new nurse caring for the client is informed about the results. Which intervention identified by the new nurse indicates a need for further teaching?
- A. Restricting visitors with colds or respiratory infections
- B. Removing all live plants, flowers, and stuffed animals in the client's room
- C. Placing the client on a low-bacteria diet that excludes raw foods and vegetables
- D. Padding the side rails and removing all hazardous and sharp objects from the room
Correct Answer: D
Rationale: Padding the side rails and removing all hazardous and sharp objects from the environment would be instituted if the client is at risk for bleeding. This client is at risk for infection. When the WBC count is less than 5000 mm^3 (5 x 10^9/L), visitors should be screened for the presence of infection, and any visitors or staff with colds or respiratory infections should not be allowed in the client's room. All live plants, flowers, and stuffed animals are removed from the client's room. The client is placed on a low-bacteria diet that excludes raw fruits and vegetables.
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When caring for a client with myasthenia gravis who is receiving anticholinesterase drug therapy, the nurse must be able to distinguish cholinergic crisis from myasthenic crisis. Which of the following symptoms is not present in cholinergic crisis?
- A. Improved muscle strength after I.V. administration of edrophonium chloride (Tensilon).
- B. Increased weakness.
- C. Diaphoresis.
- D. Increased salivation.
Correct Answer: A
Rationale: Improved muscle strength after edrophonium indicates myasthenic crisis, not cholinergic crisis, which involves excessive anticholinesterase effects.
During a home visit to a primiparous client 1 week postpartum who is bottle-feeding her neonate, the clientiant tells the nurse that her mother has suggested that she feed the neonate cereal so he will sleep through the night. Which of the following would be the nurse's best response?
- A. It is permissible to give the baby cereal if it is thinned with formula.'
- B. The time for starting cereal varies, so check with your pediatrician.'
- C. Formula is the food best digested by the baby until about 4 to 6 months of age.'
- D. If cereal is given too early in life, the undigested food can lead to a need for surgery.'
Correct Answer: C
Rationale: Formula is best for infants until 4-6 months, as early introduction of solids like cereal can cause digestive issues.
The nurse cares for a client receiving fludrocortisone acetate for the treatment of Addison's disease. When monitoring the client for improvement, what anticipated therapeutic effect of this medication will the nurse focus on?
- A. Promote electrolyte balance.
- B. Stimulate thyroid production.
- C. Stimulate the immune response.
- D. Stimulate thyrotropin production.
Correct Answer: A
Rationale: Fludrocortisone acetate is a long-acting oral medication with mineralocorticoid and moderate glucocorticoid activity that may be used for long-term management of Addison's disease. Mineralocorticoids act on the renal distal tubules to enhance the reabsorption of sodium and chloride ions and the excretion of potassium and hydrogen ions. The client can rapidly develop hypotension and fluid and electrolyte imbalance if the medication is discontinued abruptly. The medication does not affect the immune response or thyroid or thyrotropin production.
A client, admitted to the emergency department reporting severe, radiating chest pain, is extremely restless, frightened, and dyspneic. Immediate admission prescriptions include oxygen by nasal cannula at 4 L per minute; troponin, creatinine phosphokinase, and isoenzymes blood levels; a chest x-ray; and a 12-lead ECG. Which action should the nurse take first?
- A. Obtain the 12-lead ECG.
- B. Draw the blood specimens.
- C. Apply the oxygen to the client.
- D. Schedule the chest x-ray study.
Correct Answer: C
Rationale: The first action would be to apply the oxygen because the client can be experiencing myocardial ischemia. The ECG can provide evidence of cardiac damage and the location of myocardial ischemia. However, oxygen is the priority to prevent further cardiac damage. Drawing the blood specimens would be done after oxygen administration and just before or after the ECG, depending on the situation. Although the chest x-ray can show cardiac enlargement, having the chest x-ray would not influence immediate treatment.
An infant is at risk for an ileus after surgery to correct intussusception. Which observation should the nurse not include in an assessment for this complication?
- A. Measurement of urine specific gravity.
- B. Assessment of bowel sounds.
- C. Characteristics of the first stool.
- D. Measurement of gastric output.
Correct Answer: A
Rationale: Urine specific gravity is unrelated to assessing for ileus, which involves monitoring bowel sounds, stool characteristics, and gastric output to detect gastrointestinal function.