Nokea
A nurse is caring for a patient who is receiving chemotherapy. The nurse should monitor for signs of which of the following complications?
- A. Anemia.
- B. Hyperkalemia.
- C. Neutropenia.
- D. Hypocalcemia.
Correct Answer: C
Rationale: The correct answer is C: Neutropenia. Chemotherapy can suppress bone marrow function, leading to a decrease in neutrophils (a type of white blood cell), causing neutropenia. This increases the risk of infection. Monitoring for signs of infection is crucial in patients receiving chemotherapy to prevent serious complications. Anemia (A) is a common side effect of chemotherapy but is not directly related to infection risk. Hyperkalemia (B) and hypocalcemia (D) are less likely to be immediate complications of chemotherapy compared to neutropenia.
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What assessment framework provides additional modesty for clients, such as teenage girls?
- A. Body systems
- B. Functional
- C. Focused
- D. Head to toe
Correct Answer: D
Rationale: The correct answer is D: Head to toe. This assessment framework allows for modesty by assessing one body part at a time, starting from the head down to the toe. This approach ensures clients, especially teenage girls, feel comfortable and respected during the assessment process. Other choices like A (Body systems) involve assessing multiple body parts simultaneously, potentially compromising modesty. Functional assessment (B) focuses on assessing specific functions rather than individual body parts, which may not address the modesty concern. Focused assessment (C) targets a specific area of concern, which may not provide a comprehensive evaluation while also potentially overlooking modesty concerns.
What should be done for a client who is post-op and develops a fever within the first 48 hours?
- A. Administer antipyretics
- B. Monitor for signs of infection
- C. Administer fluids
- D. Perform an abdominal assessment
Correct Answer: B
Rationale: The correct answer is B: Monitor for signs of infection. Within the first 48 hours post-op, fever is often indicative of an infection. Monitoring for signs such as increased pain, redness, swelling, warmth at the surgical site, elevated white blood cell count, and changes in vital signs helps in early detection and prompt treatment of infections. Administering antipyretics (choice A) may help reduce fever but does not address the underlying cause. Administering fluids (choice C) is important for hydration but does not directly address the fever's cause. Performing an abdominal assessment (choice D) is not specific to addressing fever in a post-op client.
A patient tells the nurse that he is very nervous, that he is nauseated, and that he "feels hot." This type of data would be:
- A. objective.
- B. reflective.
- C. subjective.
- D. introspective.
Correct Answer: C
Rationale: The correct answer is C: subjective. Subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient's report of feeling nervous, nauseated, and hot is subjective because it reflects their personal sensations and cannot be measured or observed directly by the nurse. Objective data (choice A) is measurable and observable, such as vital signs or physical examination findings. Reflective (choice B) and introspective (choice D) do not accurately describe the type of data provided by the patient in this scenario. The patient's symptoms are subjective because they are based on the patient's own feelings and experiences, making choice C the most appropriate answer.
Which fetal heart monitor pattern can indicate cord compression?
- A. variable decelerations
- B. early decelerations
- C. bradycardia
- D. tachycardia
Correct Answer: A
Rationale: The correct answer is A: variable decelerations. Variable decelerations are abrupt decreases in fetal heart rate that vary in depth, duration, and timing, which can indicate cord compression. The variability in these decelerations suggests that the umbilical cord is being compressed intermittently.
Early decelerations (B) are usually caused by head compression during contractions and mirror the contractions, not indicating cord compression. Bradycardia (C) is a slow heart rate, which can be caused by various factors but is not specific to cord compression. Tachycardia (D) is a fast heart rate, which can also be caused by various factors but is not typically associated with cord compression.
What should the nurse assess first in a client with severe abdominal pain?
- A. Assess vital signs
- B. Administer oxygen
- C. Perform an ECG
- D. Monitor serum glucose levels
Correct Answer: A
Rationale: The correct answer is A: Assess vital signs. Vital signs provide crucial information on the client's overall condition and can help identify any life-threatening issues. Monitoring vital signs such as blood pressure, heart rate, respiratory rate, and temperature can guide immediate interventions and determine the urgency of further assessments or treatments. Administering oxygen (B) would be appropriate after assessing vital signs. Performing an ECG (C) may be indicated later but is not the priority in this acute situation. Monitoring serum glucose levels (D) is not typically the first assessment in a client with severe abdominal pain.