Nokea
A nurse is reinforcing teaching with a client who is scheduled for a lumbar puncture. Which of the following instructions should the nurse include?
- A. Avoid eating after midnight before the procedure.
- B. Lie flat for 4 to 6 hours after the procedure.
- C. Expect general anesthesia during the procedure.
- D. Avoid drinking fluids for 12 hours before the procedure.
Correct Answer: B
Rationale: Lying flat for 4 to 6 hours after a lumbar puncture prevents cerebrospinal fluid leakage and reduces headache risk.
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A nurse is caring for a client who is receiving chemotherapy. Which of the following laboratory values should the nurse monitor?
- A. White blood cell count
- B. Blood urea nitrogen
- C. Serum albumin
- D. Cholesterol
Correct Answer: A
Rationale: Chemotherapy can cause leukopenia, so monitoring white blood cell count is essential to assess infection risk.
A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?
- A. Instruct the parents to avoid bringing fresh flowers into the room.
- B. Use an N95 respirator.
- C. Initiate contact precautions.
- D. Place the child in a room that has a HEPA filtration system.
Correct Answer: C
Rationale: Initiating contact precautions is correct. Clostridium difficile is highly contagious and spreads through spores that can survive on surfaces. Contact precautions, including the use of gloves and gowns and proper hand hygiene with soap and water, help prevent transmission.
A nurse is reinforcing teaching with a client who has a new prescription for a fluticasone inhaler. Which of the following instructions should the nurse include?
- A. Use it as needed for shortness of breath.
- B. Rinse your mouth after use.
- C. Take it once daily.
- D. Shake the inhaler before use.
Correct Answer: B
Rationale: Rinsing the mouth after using a fluticasone inhaler prevents oral thrush, a common side effect of inhaled corticosteroids.
A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?
- A. Anaphylactic
- B. Acute hemolytic
- C. Febrile
- D. Circulatory overload
Correct Answer: A
Rationale: An anaphylactic reaction is correct. Symptoms such as urticaria (hives) and wheezing indicate a severe allergic reaction, which can progress to anaphylaxis. This reaction is caused by a hypersensitivity to plasma proteins in the transfused blood and requires immediate intervention, including stopping the transfusion and administering epinephrine.
A nurse is caring for a client who has a new diagnosis of Cushing's syndrome. Which of the following findings should the nurse expect?
- A. Weight gain
- B. Weight loss
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: Weight gain, especially in the trunk, is a common symptom of Cushing's syndrome due to excess cortisol.