Nokea
A nurse is caring for a client who is undergoing chemotherapy. Current laboratory values are noted on the chart. Which action would be most appropriate for the nurse to implement?
- A. Wearing a protective gown and particulate respiratory mask when completing treatments.
- B. Washing hands before and after entering the room.
- C. Restricting visitors.
- D. Contacting the physician for an order for hematopoietic factors such as erythropoietin (Epogen, Procrit).
Correct Answer: B
Rationale: With a low white blood cell count (1,600/mm³) and absolute neutrophil count (<1,000/mm³), hand washing before and after entering the room is critical to prevent infection in this neutropenic client.
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Which symptom suggests a complication post-renal surgery?
- A. Urine output of 25 mL/hour.
- B. Temperature of 99°F.
- C. Mild incisional pain.
- D. Clear urine.
Correct Answer: A
Rationale: Low urine output (25 mL/hour) may indicate obstruction or renal impairment.
Allopurinol (Zyloprim), 200 mg/day, is prescribed for the client with renal calculi to take at home. The nurse should teach the client about which the following adverse effects of this medication?
- A. Retinopathy.
- B. Maculopapular rash.
- C. Nasal congestion.
- D. Dizziness.
Correct Answer: B
Rationale: Maculopapular rash is a common adverse effect of allopurinol, requiring monitoring due to potential allergic reactions.
A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following?
- A. Respiratory rate greater than 16 breaths/minute.
- B. Continuous bubbling in the water-seal chamber.
- C. Fluid in the chest tube.
- D. Fluctuation of fluid in the water-seal chamber.
Correct Answer: B
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak, requiring physician notification. A respiratory rate >16 is normal. Fluid in the tube and fluctuation are expected.
Which teaching point is essential for a client with a seizure disorder?
- A. Avoid all physical activity.
- B. Take medications as prescribed.
- C. Limit sleep to 6 hours nightly.
- D. Restrict fluid intake.
Correct Answer: B
Rationale: Taking medications as prescribed is essential to control seizures and prevent recurrence.
After cataract removal surgery, the client is instructed to report sharp pain in the operative eye because this could indicate which of the following postoperative complications?
- A. Detached retina.
- B. Prolapse of the iris.
- C. Extracapsular erosion.
- D. Intraocular hemorrhage.
Correct Answer: D
Rationale: Sharp pain in the operative eye post-cataract surgery may indicate intraocular hemorrhage, which can increase intraocular pressure and cause severe pain, requiring immediate intervention.