Nokea
A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects?
- A. Anorexia and malnutrition
- B. Diarrhea and dehydration
- C. Bleeding from the gums
- D. Full body alopecia
Correct Answer: C
Rationale: Myelosuppression can cause thrombocytopenia, increasing bleeding risk, including from gums. Anorexia, diarrhea, and alopecia are chemotherapy side effects but not directly related to myelosuppression.
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A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
- A. Heart rate
- B. Weight
- C. Urine output
- D. BP
Correct Answer: A
Rationale: A decrease in heart rate indicates improved cardiac output and reduced tachycardia, suggesting adequate fluid replacement. Weight may increase, urine output should increase, and BP stabilizes but is less direct an indicator.
In reviewing a patient's complete blood count (CBC) results, the nurse notes a 'shift to the left.' What is the significance of these results?
- A. There is an elevated number of immature thrombocytes.
- B. There is an elevated number of immature neutrophils (bands),
- C. There is an elevated number of mature neutrophils (segs)
- D. There is an elevated number of mature erythrocytes
Correct Answer: B
Rationale: A 'shift to the left' indicates an increase in immature neutrophils (bands), often signaling acute infection or inflammation as the body releases more neutrophils to fight pathogens.
A nurse is caring for a postoperative client following abdominal surgery. Which of the following findings should cause the nurse to anticipate the client might be experiencing a hemorrhage?
- A. Hypotension
- B. Diaphoresis
- C. Bradycardia
- D. Diarrhea
Correct Answer: A
Rationale: Hypotension and tachypnea are signs of hemorrhage due to decreased blood volume and compensatory increased respiratory rate. Diaphoresis may occur but is less specific, while bradycardia and diarrhea are not typical.
A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?
- A. Avoid crowds
- B. Eat plenty of fresh fruits and vegetables
- C. Take temperature weekly.
- D. Perform mild exercise, such as gardening
Correct Answer: A
Rationale: Neutropenic patients are highly susceptible to infections. Crowded places increase the risk of exposure to pathogens. Fresh fruits and vegetables can harbor bacteria, posing a risk for infection in neutropenic individuals. Neutropenic patients should monitor their temperature daily, not weekly, to detect infections early. Gardening can expose individuals to soil-borne organisms that could lead to infections.
A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?
- A. Eating a high fiber diet will reduce my risk for developing skin cancer
- B. should check my skin monthly for any changes.
- C. should use sunscreen even on cloudy days.
- D. should avoid the use of tanning booths.
Correct Answer: A
Rationale: There is no evidence that a high-fiber diet reduces skin cancer risk, indicating a misunderstanding. Other statements reflect correct preventive measures.