Nokea
A nurse is contributing to the plan of care for an older adult client who has a WBC of 2000/mm³ after three rounds of chemotherapy. Which of the following interventions should the nurse include in the plan?
- A. Serve cooked fruit with meals.
- B. Report temperatures greater than 39.5°C (102.3°F) lasting more than 4 hours.
- C. Place the client in a room with negative-pressure airflow.
- D. Instruct client to use an incentive spirometer every 4 hours.
Correct Answer: A
Rationale: Serving cooked fruit reduces infection risk by eliminating pathogens, appropriate for a client with low WBC counts.
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A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client's right leg?
- A. Abduction.
- B. Internal rotation.
- C. External rotation.
- D. Adduction.
Correct Answer: A
Rationale: Abduction prevents hip dislocation by keeping the leg away from the midline, maintaining joint stability post-arthroplasty.
A nurse is collecting data for a client who has fluid volume deficit. Which of the following is an expected finding?
- A. Increased urine ketones.
- B. Increased urine specific gravity.
- C. Decreased hematocrit.
- D. Decreased urine output.
Correct Answer: B
Rationale: Increased urine specific gravity is expected in fluid volume deficit, indicating concentrated urine due to decreased fluid intake or excessive fluid loss.
A nurse is reinforcing teaching with a middle-aged client about hypertension. Which of the following information should the nurse include in the teaching?
- A. Plan to have potassium blood levels checked when taking thiazide diuretics.
- B. Limit alcohol consumption to 3 drinks a day when hypertensive.
- C. Set your goal body weight within 25% of ideal body weight.
- D. Plan to lower sodium intake to 3,000 mg each day.
Correct Answer: A
Rationale: Monitoring potassium levels is essential with thiazide diuretics, which can cause hypokalemia, ensuring safe management of hypertension.
A nurse is reinforcing teaching with a client who has a new prescription for phenazopyridine. The nurse should reinforce to the client to expect which of the following while taking this medication?
- A. Lethargy.
- B. Reddish-orange urine.
- C. Burning during urination.
- D. Visual disturbances.
Correct Answer: B
Rationale: Reddish-orange urine is a common and expected side effect of phenazopyridine, which is harmless but can stain clothing.
A nurse in a clinic is collecting data from a client who has cystitis. Which of the following findings should the nurse expect?
- A. Suprapubic tenderness.
- B. Proteinuria.
- C. Generalized edema.
- D. Oliguria.
Correct Answer: A
Rationale: Suprapubic tenderness is common in cystitis due to bladder wall irritation and inflammation.