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A patient with thrombocytopenia has a platelet count of 80,000. It will be most important to teach the client about:
- A. Measures to reduce the risk of bleeding
- B. Increasing the fluid intake
- C. Activities to improve oxygenation
- D. Ways to conserve energy
Correct Answer: A
Rationale: Thrombocytopenia (low platelet count) increases bleeding risk. Teaching measures to reduce bleeding (e.g. avoiding trauma using soft toothbrushes) is critical. Fluid intake oxygenation and energy conservation are less directly related to the condition.
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The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?
- A. Notify the physician.
- B. Record the reading as the only action.
- C. Turn the client and recheck the reading.
- D. Place the client supine.
Correct Answer: A
Rationale: An ICP of 66 mmHg is dangerously high (normal <20 mmHg), requiring immediate physician notification for intervention. Recording only (B), turning (C), or supine positioning (D) delays critical action.
The client is prescribed warfarin (Coumadin). Which food should the nurse instruct the client to limit?
- A. Spinach
- B. Apples
- C. Chicken
- D. Rice
Correct Answer: A
Rationale: Spinach is high in vitamin K, which antagonizes warfarin’s anticoagulant effect, potentially reducing its efficacy. Apples, chicken, and rice have negligible vitamin K.
A client with a history of atrial fibrillation is admitted with complaints of fatigue. The nurse should give priority to:
- A. Monitoring heart rate
- B. Administering pain medication
- C. Monitoring respiratory rate
- D. Administering diuretics
Correct Answer: A
Rationale: Fatigue in atrial fibrillation may indicate reduced cardiac output, so monitoring heart rate is the priority.
A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:
- A. Hemolytic transfusion reaction
- B. Febrile transfusion reaction
- C. Circulatory overload
- D. Allergic transfusion reaction
Correct Answer: D
Rationale: A hemolytic transfusion reaction would be characterized by fever, chills, chest pain, hypotension, and tachypnea. Fever, chills, and headaches are indicative of a febrile transfusion reaction. Circulatory overload is manifest by dyspnea, cough, and pulmonary crackles. Urticaria, pruritus, wheezing, and anxiety are indicative of an allergic transfusion reaction.
While the nurse is taking a male client's blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:
- A. Politely tells the client, 'Keep your hands off'
- B. Ignores the remarks and hopes he will not try it again
- C. Confronts the remarks but attempts not to reject the client
- D. Leaves the room in order to compose herself
Correct Answer: C
Rationale: By confronting the remarks, she can recognize that his feelings of attraction may be normal but are not appropriate within the context of their nurse-client relationship.