Nokea
A nurse is preparing to mix and administer chemotherapy. What equipment would be unnecessary to obtain?
- A. Surgical gloves
- B. Luer lok fitting IV tubing
- C. Surgical hat cover
- D. Disposable long-sleeve gown
Correct Answer: C
Rationale: Chemotherapy requires protective equipment (gloves, gown, Luer lok tubing to prevent leaks), but a surgical hat cover is unnecessary unless in a sterile field, which isn't typical for chemo administration.
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A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
- A. Taking hourly blood pressures with mechanical cuff
- B. Encouraging fluid intake of at least 200 mL per hour
- C. Position in high Fowler's with knee gatch raised
- D. Administering Tylenol as ordered
Correct Answer: B
Rationale: Hydration is the highest priority in sickle cell crisis to prevent further sickling of red blood cells and to promote blood flow, reducing the risk of complications.
The nurse is obtaining a history on a 74-year-old client. Which statement made by the client would alert the nurse to a possible fluid and electrolyte imbalance?
- A. My skin is always so dry.'
- B. I often use a laxative for constipation.'
- C. I have always liked to drink a lot of water.'
- D. I sometimes have a problem with dribbling urine.'
Correct Answer: B
Rationale: Frequent laxative use can cause fluid and electrolyte losses (e.g., potassium, sodium), leading to imbalances, unlike the other statements.
The nurse is caring for a client with B-Thalassemia major. Which therapy is used to treat Thalassemia?
- A. IV fluids
- B. Frequent blood transfusions
- C. Oxygen therapy
- D. Iron therapy
Correct Answer: B
Rationale: Frequent transfusions manage severe anemia in B-Thalassemia major.
Which of the following best describes the language of a 24-month-old?
- A. Doesn't understand yes and no
- B. Understands the meaning of words
- C. Able to verbalize needs
- D. Asks 'why?' to most statements
Correct Answer: C
Rationale: A 24-month-old can verbalize needs using simple words or phrases, reflecting their developing language skills.
A pregnant client is keeping a 'kick count' log during the last trimester. Which of the following may indicate fetal distress?
- A. Fewer than 5 movements within 2 hours
- B. Fewer than 5 movements within 1 hour
- C. Fewer than 10 movements within 2 hours
- D. Fewer than 10 movements within 1 hour
Correct Answer: C
Rationale: Fewer than 10 movements in 2 hours (C) suggests fetal distress, as normal is >10 movements in 2 hours. Other options (A, B, D) set incorrect thresholds.