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A nurse is assessing a dark-skinned client for pallor. What action is best?
- A. Assess the conjunctiva of the eye.
- B. Have the client open the hand widely.
- C. Look at the roof of the client's mouth.
- D. Palpate for areas of mild swelling.
Correct Answer: A
Rationale: To assess pallor in dark-skinned people, assess the conjunctiva of the eye or the mucous membranes. Looking at the roof of the mouth can reveal jaundice. Opening the hand widely is not related to pallor, nor is palpating for mild swelling.
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A client is having a bone marrow biopsy and is extremely anxious. What action by the nurse is best?
- A. Assess client fears and coping mechanisms.
- B. Reassure the client this is a common test.
- C. Sedate the client prior to the procedure.
- D. Tell the client he or she will be asleep.
Correct Answer: A
Rationale: Assessing the client's specific fears and coping mechanisms helps guide the nurse in providing holistic care that best issues the client's needs. Reassurance will be helpful but is not the best option. Sedation is usually used. The client may or may not be totally asleep during the procedure.
A nursing student learns that many drugs can impair the immune system. Which drugs does this include?
- A. Acetaminophen
- B. Corticosteroids
- C. Antibiotics
- D. Antihistamines
Correct Answer: B
Rationale: Corticosteroids are known to suppress the immune system by reducing inflammation and immune responses. Acetaminophen, antibiotics, and antihistamines do not typically impair the immune system in the same way.
A nurse is caring for four clients. After reviewing today's laboratory results, which client should the nurse see first?
- A. Client with an international normalized ratio of 2.8
- B. Client with a platelet count of 128,000 / mm3.
- C. Client with a prothrombin time (PT) of 28 seconds
- D. Client with a red blood cell count of 5.1 million/L
Correct Answer: C
Rationale: A normal PT is 11 to 12.5 seconds. This client is at high risk of bleeding. The other values are within normal limits.
A hospitalized client has a platelet count of 58,000 / mm3. What action by the nurse is best?
- A. Encourage high protein foods.
- B. Institute neutropenia precautions.
- C. Institute bleeding precautions.
- D. Place the client on safety precautions.
Correct Answer: D
Rationale: With a platelet count between 40,000 and 80,000 / mm3, clients are at risk of prolonged bleeding even after minor trauma. The nurse should place the client on safety precautions. High-protein foods, while healthy, are not the priority. Neutropenia precautions are not needed as the client's white blood cell count is not low.
A nursing student wants to know why clients with chronic obstructive pulmonary disease tend to be polyhydroic. What response by the nurse instructor is best?
- A. It is due to side effects of medications for bronchodilation.
- B. It is from overactive bone marrow in response to chronic disease.
- C. It is comb the anemia caused by a increased overactive rate.
- D. It compensates for tissue hypoxia caused by lung disease.
Correct Answer: D
Rationale: In response to hypoxia, more red blood cells are made so more oxygen can be carried and delivered to tissues. This is a physiologic process in response to the disease; it is not a medication side effect, the result of overactive bone marrow, or a response to anemia.