Nokea
A nurse is obtaining a health history from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?
- A. Slurred speech
- B. Confusion
- C. Pain
- D. Fatigue
Correct Answer: D
Rationale: Fatigue is a hallmark symptom of iron deficiency anemia due to decreased oxygen-carrying capacity of the blood, leading to tiredness and lack of energy. Slurred speech, confusion, and pain are not typical symptoms unless associated with severe or advanced stages.
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A nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first?
- A. Elevate the limb and apply ice.
- B. Apply a tourniquet just below the elbow.
- C. Apply direct pressure over the wound.
- D. Clean the wound.
Correct Answer: C
Rationale: Applying direct pressure is the first-line intervention to control profuse bleeding, stopping or reducing blood loss immediately.
In reviewing a patient's complete blood count (CBC) results, the nurse notes a 'shift to the left.' What is the significance of these results?
- A. There is an elevated number of immature thrombocytes.
- B. There is an elevated number of immature neutrophils (bands),
- C. There is an elevated number of mature neutrophils (segs)
- D. There is an elevated number of mature erythrocytes
Correct Answer: B
Rationale: A 'shift to the left' indicates an increase in immature neutrophils (bands), often signaling acute infection or inflammation as the body releases more neutrophils to fight pathogens.
A nurse is providing teaching to a group of clients about the changes that occur in the eye when clients experience retinal detachment. Which of the following statements should the nurse include in the teaching?
- A. Vision changes occur suddenly due to complete obstruction of aqueous humor outflow
- B. Vision changes occur when retinal tissue pulls away from the blood vessels in the eye
- C. Vision changes occur when the retina begins to breakdown and collect bits of debris
- D. Vision changes occur when the cloudy lens alters the passage of light through the eye
Correct Answer: B
Rationale: Retinal detachment occurs when the retina separates from its supporting tissues and blood vessels, leading to vision loss. Other options describe different eye conditions like glaucoma, macular degeneration, or cataracts.
A nurse is caring for a client who has shingles with multiple skin lesions. Which of the following actions by the nurse require intervention by the nurse's supervisor?
- A. The nurse wears a gown when bathing the client.
- B. The nurse admits another client who has shingles to the client's double room.
- C. The nurse wears gloves when providing direct care to the client.
- D. The nurse wears an N95 respirator mask.
Correct Answer: B
Rationale: Shingles is highly contagious, especially to those without chickenpox immunity. Cohorting clients with shingles in a shared room risks viral transmission. Other actions are appropriate precautions.
A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is the nurse's priority?
- A. Notifying the provider
- B. Stopping the transfusion
- C. Covering the client with a blanket
- D. Assessing the client's skin for a rash
Correct Answer: B
Rationale: Chills and back pain suggest a serious transfusion reaction, like hemolytic reaction. Stopping the transfusion immediately is the priority to prevent further complications.