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A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemotherapy. Which of the following is the nurse's priority instruction for measuring vital signs for this client?
- A. Don't measure the client's temperature rectally.'
- B. Count the client's radial pulse for 30 seconds & multiply by 2.'
- C. Don't let the client know you are counting her respirations.'
- D. Let the client rest for 5 minutes before you measure her BP.'
Correct Answer: A
Rationale: Correct Answer: A: Don't measure the client's temperature rectally.
Rationale: Clients with low platelet count are at risk for bleeding. Rectal temperature measurement poses a risk of mucosal injury and bleeding due to the fragility of the rectal mucosa. Therefore, the nurse's priority instruction is to avoid rectal temperature measurement to prevent any potential harm to the client.
Summary:
B: Counting the radial pulse for 30 seconds and multiplying by 2 is a valid method for measuring heart rate but is not the priority instruction in this case.
C: It is important for the client to be aware that respirations are being counted to ensure accurate measurement. However, this is not the priority instruction for vital sign measurement.
D: Allowing the client to rest for 5 minutes before measuring blood pressure is a good practice, but it is not the priority instruction compared to avoiding rectal temperature measurement for a client with low platelet count.
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A nurse is caring for a client who is 1 day postop following a total knee arthroplasty. The client states his pain level is a 10 on a scale of 0-10. After reviewing the client's medication administration record, which of the following medications should the nurse administer?
- A. Meperidine (Demerol) 75 mg IM
- B. Fentanyl 50 mcg/hr transdermal patch
- C. Morphine 2 mg IV
- D. Oxycodone 10 mg PO
Correct Answer: C
Rationale: The correct answer is C: Morphine 2 mg IV. Postoperative pain management is crucial for patient comfort and recovery. IV morphine is a potent opioid analgesic that provides quick and effective pain relief. The IV route allows for rapid onset of action, making it suitable for severe pain like in this case. Meperidine (choice A) is not recommended due to its toxic metabolite accumulation risk. Fentanyl patch (choice B) has a delayed onset and is not ideal for immediate pain relief. Oxycodone PO (choice D) is a less potent oral option compared to IV morphine for severe pain.
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed & is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?
- A. Increase the oxygen flow.
- B. Assist the client to Fowler's position.
- C. Promote removal of pulmonary secretions.
- D. Obtain a specimen for arterial blood gases.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to Fowler's position. This is the priority intervention because elevating the client to Fowler's position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and allowing better ventilation. Increasing oxygen flow (Choice A) may be needed, but positioning takes precedence. Promoting removal of pulmonary secretions (Choice C) is important but not the priority in this case. Obtaining arterial blood gases (Choice D) is important for assessing oxygenation status but can be done after ensuring optimal positioning.
A nurse in an outpatient clinic is caring for a client who states she is trying to get pregnant. The client currently takes a Category D pregnancy risk medication for the control of seizures. Which of the following statements by the nurse is appropriate?
- A. This medication is prescribed if necessary but is known to cause adverse effects to the fetus.
- B. This medication has evidence indicating that it is safe to take during pregnancy and will not harm the fetus.
- C. This medication cannot be taken during pregnancy because the risk outweighs the potential benefits.
- D. This medication hasn't been studied in pregnant women but is believed to be safe for the fetus.
Correct Answer: A
Rationale: The correct answer is A. Category D medications have shown evidence of risk to the fetus in human studies but potential benefits may outweigh risks in certain situations. The nurse should inform the client about the risks and benefits of continuing the medication while trying to conceive. Choice B is incorrect because Category D medications are not considered safe during pregnancy. Choice C is incorrect as it is not entirely true that the risk always outweighs the benefits. Choice D is incorrect because assuming safety without evidence is risky. The nurse should provide accurate information to guide the client's decision-making.
A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all.
- A. Restlessness
- B. Tachypnea
- C. Bradycardia
- D. Confusion
- E. Pallor
Correct Answer: A,B,E
Rationale: Correct Answer: A, B, E
Rationale:
1. Restlessness: Early sign of hypoxemia due to the body's attempt to increase oxygen intake.
2. Tachypnea: Increased respiratory rate compensates for low oxygen levels in the blood.
3. Pallor: Skin paleness indicates poor oxygenation of tissues due to hypoxemia.
Incorrect Choices:
C: Bradycardia - Bradycardia is a late sign of hypoxemia, not an early indication.
D: Confusion - Confusion is a late sign of severe hypoxemia affecting the brain function.
A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crusting. Which of the following should the nurse suspect?
- A. Allergic reaction
- B. Ringworm
- C. Systemic lupus erythematosus
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. The presentation of linear clusters of fluid-containing vesicles with crusting is characteristic of herpes zoster, also known as shingles. This viral infection is caused by the reactivation of the varicella-zoster virus, which initially causes chickenpox. The linear distribution of the vesicles along a dermatome is a key feature of herpes zoster. The other choices are incorrect because: A: Allergic reactions typically present with hives or itching, not vesicles with crusting. B: Ringworm presents as circular, red, scaly patches, not linear clusters of vesicles. C: Systemic lupus erythematosus is an autoimmune disease that manifests with a butterfly rash on the face, joint pain, and other systemic symptoms, not vesicles. Therefore, the nurse should suspect herpes zoster based on the presentation described.