Nokea
A nurse is caring for an adult client who has acute lymphocytic leukemia. The client is refusing blood products. Which of the following responses should the nurse make?
- A. Not receiving blood will slow down your recovery.
- B. You need to talk with your doctor about this.
- C. Why are you refusing to receive blood products?
- D. I understand that you decided not to receive blood products.
Correct Answer: D
Rationale: Acknowledging the refusal respects autonomy and builds trust, avoiding confrontation.
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A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?
- A. I love to eat apples and black-eyed peas.
- B. I drink an average of 2,000 milliliters of water daily.
- C. I take a prescribed opioid pain medication at bedtime.
- D. I drink two hot cups of coffee each morning.
Correct Answer: C
Rationale: Opioids slow bowel motility, increasing constipation risk, unlike fiber-rich foods or hydration.
A nurse is preparing to administer ampicillin to a school-age child who weighs 55 lb. The provider prescribes 50 mg/kg/day in 4 equal doses. Available is ampicillin oral suspension 125 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 12.5 mL
Rationale: 55 lb = 25 kg; 25 kg × 50 mg/kg/day = 1250 mg/day; 1250 mg ÷ 4 = 312.5 mg/dose; 312.5 mg ÷ (125 mg/5 mL) = 12.5 mL.
A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)
- A. Squeeze the client's finger until a blood drop forms.
- B. Apply clean gloves.
- C. Prick the side of the client's finger.
- D. Elevate the client's hand above the level of the heart.
- E. Cleanse the client's finger with an iodine swab.
Correct Answer: B,C,E
Rationale: B: Gloves ensure infection control. C: Side prick is correct technique. E: Iodine disinfects; A risks hemolysis, D impedes flow.
A nurse is collecting data from a client who has a BMI of 29. The nurse should document that the client is in which of the following weight categories?
- A. Overweight
- B. Ideal body weight
- C. Obese
- D. Underweight
Correct Answer: A
Rationale: A BMI of 29 falls in the overweight range (25-29.9), per standard classifications.
A nurse is assisting in the care of a client who just started receiving a blood transfusion 5 min ago. Which of the following findings should be reported first to the provider?
- A. Headache
- B. Dyspnea
- C. Hyperthermia
- D. Urticaria
Correct Answer: B
Rationale: Dyspnea may indicate a severe transfusion reaction like TRALI, requiring urgent reporting.