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A nurse is providing teaching to a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching?
- A. I will avoid crowds.
- B. I will wash my toothbrush weekly.
- C. I will take my temperature daily.
- D. I will eat plenty of fresh fruits and vegetables.
Correct Answer: A, C
Rationale: Correct Answer: A, C
Rationale:
A: Avoiding crowds helps reduce the risk of exposure to infections, crucial for neutropenic clients.
C: Taking temperature daily allows early detection of fever, a sign of infection.
B: Weekly toothbrush washing does not directly impact infection risk.
D: Fresh fruits and vegetables are good for health but not specific to neutropenia management.
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A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hr ago. Which of the following findings should the nurse expect?
- A. Edema at the site
- B. Severe pain at the site
- C. Epithelialization at the site
- D. Blistering at the site
Correct Answer: A
Rationale: The correct answer is A: Edema at the site. After sustaining major full-thickness burns, the body initiates an inflammatory response, leading to increased capillary permeability and fluid accumulation in the interstitial space, causing edema. This is a normal physiological response to burns. Edema helps in the healing process by providing nutrients and oxygen to the damaged tissues. Choices B, C, and D are incorrect. Severe pain may not be present initially due to nerve damage from the burn. Epithelialization typically occurs during the later stages of burn healing. Blistering is more commonly seen in partial-thickness burns rather than full-thickness burns.
Which actions should the nurse take? (Select all that apply)
- A. Anticipate client to be prepped for cardiac catheterization
- B. Assist with a continuous heparin infusion
- C. Encourage the client to ambulate
- D. Anticipate an increased dosage of metoprolol
- E. Obtain a prescription for client to be NPO
- F. Request a prescription for an antibiotic
Correct Answer: A, B, D,E
Rationale: The nurse should anticipate cardiac catheterization prep (A) to ensure client readiness. Continuous heparin infusion (B) prevents clot formation during the procedure. Increased metoprolol dosage (D) may be needed for cardiac stability. NPO status (E) is crucial to prevent complications during the procedure. Ambulation (C) may be contraindicated due to the invasive nature of the procedure. Antibiotics (F) are not routinely needed for cardiac catheterization prep.
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?
- A. Photophobia
- B. Bradycardia
- C. Intermittent headache
- D. Petechiae on the chest
Correct Answer: A
Rationale: The correct answer is A: Photophobia. Meningitis is an inflammation of the meninges, the protective membranes covering the brain and spinal cord. Photophobia, or sensitivity to light, is a classic symptom of meningitis due to the irritation of the meninges causing increased sensitivity to light. This occurs because the inflamed meninges lead to stimulation of the nerves around the brain, resulting in discomfort when exposed to light.
Bradycardia (B) is not typically associated with meningitis. Intermittent headache (C) is vague and can be present in various conditions. Petechiae on the chest (D) are more commonly seen in conditions like meningococcal meningitis.
A nurse is planning care for a client who is 12 hr postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?
- A. Check the client's blood pressure every 8 hr.
- B. Assess urine output hourly.
- C. Administer opioids PO.
- D. Monitor for hypokalemia as a manifestation of acute rejection.
Correct Answer: B
Rationale: The correct answer is B: Assess urine output hourly. This is important postoperatively to monitor kidney function and ensure adequate perfusion. Hourly assessment allows for early detection of any changes in urine output, which can indicate complications such as acute kidney injury. Checking blood pressure every 8 hours (Choice A) may be necessary but is less critical in the immediate postoperative period. Administering opioids PO (Choice C) can mask changes in the client's condition and should be avoided until kidney function is stable. Monitoring for hypokalemia (Choice D) is important but not the priority in the immediate postoperative period.
A nurse is caring for a client who is experiencing an exacerbation of heart failure. Thenurse is
assessing the client 24 hr later. How should the nurse interpret the findings related to the
diagnosis of heart failure? For each finding, click to specify whe ther the finding is unrelated to
the diagnosis, a sign of potential improvement, or a sign of potential worsening condition. Diagnostic Results
Hgb 8.4 g/dL (12 to 18 g/dL)
Hct 42% (37% to 47%)
WBC count 9,800/mm3 (5,000 to 10,000/ mm3) Potassium 432
mEq/L (3.5 to 5 mEq/L)
- A. Lung sounds clean
- B. Creatinine 1.8 mm/dl
- C. Weight 113kg(249 lb)
- D. WBC Count 11,800mm3
- E. Temperature: 38.5°C (101.3°F)
- F. Shortness of breath with exertion
Correct Answer: A, B,C,D,E
Rationale:
The correct answer is A, B, C, D, E. In heart failure exacerbation, key indicators are related to fluid overload and organ perfusion. A) Lung sounds clean indicate potential improvement in pulmonary congestion. B) Creatinine 1.8 mm/dl is important for kidney function monitoring, as worsening kidney function can occur in heart failure. C) Weight 113kg reflects fluid retention, relevant for heart failure management. D) WBC count (11,800mm3) can indicate infection, which can worsen heart failure. E) Temperature 38.5°C can suggest infection or systemic inflammatory response, which worsens heart failure.