Nokea
A nurse is assisting with the development of the plan of care for a client who has a low WBC count. Which of the following interventions should the nurse include?
- A. Obtain the client's rectal temperature every 4 hr.
- B. Prohibit fresh flowers in the client's room.
- C. Encourage the client to eat a low-protein diet.
- D. Initiate airborne precautions for the client.
- E. Monitor daily CBC.
- F. Limit visitors.
- G. Use strict hand hygiene.
Correct Answer: B
Rationale: Fresh flowers can harbor bacteria, increasing infection risk in neutropenia; rectal temps risk injury, and airborne isn't needed.
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A nurse is reviewing a client's medical history to identify risk factors for osteoporosis. The nurse should identify that which of the following findings is a risk factor for developing steps
- A. Age 45 years
- B. Regular aerobic exercise
- C. Uses NSAIDS for pain relief
- D. Smokes cigarettes
Correct Answer: D
Rationale: Smoking increases osteoporosis risk by decreasing bone mass. The other options do not directly contribute to osteoporosis development.
A nurse is caring for a client who has a prescription for propranolol for the treatment of atrial fibrillation. Which of the following actions should the nurse take?
- A. Request a dosage increase if the apical heart rate is less than 60/min.
- B. Withhold the medication if the systolic blood pressure is less than 90 mm Hg.
- C. Administer the medication with an antacid.
- D. Instruct the client to expect increased hair growth.
Correct Answer: B
Rationale: Propranolol is a beta-blocker, and it should be withheld if the systolic blood pressure is below 90 mm Hg to prevent hypotension. A heart rate below 60/min might also warrant withholding, not increasing, the dose, and the other options are unrelated to its administration.
Vital Signs
Today, 0700:
Blood pressure 122/68 mm Hg
Heart rate 99/min
Respiratory rate 20/min
Temperature 36.4° C (97.6° F)
Laboratory Results
Today, 0700:
Potassium 3.2 mEq/L (3.5 to 5 mEq/L)
Hct 44% (42% to 52%)
BUN 19 mg/dL (10 to 20 mg/dL)
Which of the following client findings should the nurse identify as a contraindication to the administration of furosemide? (Client with potassium 3.2 mEq/L)
- A. Potassium level
- B. Blood pressure
- C. Prescription for digoxin
- D. BUN
- E. Client verbal report
- F. Heart rate
- G. Respiratory rate
Correct Answer: A
Rationale: Hypokalemia (3.2 mEq/L) is a contraindication as furosemide can worsen it, risking arrhythmias.
A nurse is initiating the use of a continuous passive motion (CPM) device for a client following a total knee arthroplasty. Which of the following actions should the nurse take?
- A. Set the degree of flexion and extension as tolerated by client.
- B. Pad the CPM device with a thick pillow.
- C. Place the client in high-Fowler's position.
- D. Align the client's joints with the joints on the frame.
Correct Answer: D
Rationale: Aligning the client's joints with the CPM frame ensures proper movement and prevents injury. Flexion/extension should be preset by the provider, padding isn't typically needed, and high-Fowler's position is inappropriate for this therapy.
A nurse is reinforcing teaching with a client who is newly diagnosed with dumping syndrome. Which of the following instructions should the nurse include in the teaching?
- A. Remain upright for 30 min after eating.
- B. Eat three large meals per day.
- C. Drink water with meals.
- D. Eliminate simple sugars.
Correct Answer: D
Rationale: Dumping syndrome occurs post-gastric surgery when food moves too quickly into the small intestine, causing nausea, diarrhea, and weakness. Eliminating simple sugars is key sugars draw fluid into the gut, worsening osmotic shifts and symptoms. Remaining upright helps slow gastric emptying but isn't the primary dietary fix. Eating three large meals overloads the stomach, triggering rapid dumping, whereas small, frequent meals are recommended. Drinking water with meals dilutes stomach contents, accelerating emptying and exacerbating symptoms; fluids should be taken between meals. Cutting simple sugars (e.g., candy, soda) reduces hyperosmolarity, stabilizes digestion, and aligns with evidence-based management, improving quality of life. This instruction empowers the client to control symptoms through diet, a cornerstone of dumping syndrome care, making it the most effective teaching point.