Nokea
An adult has been diagnosed with some type of anemia. The results of his blood tests showed: decreased WBC, normal RBC, decreased HCT, decreased Hgb. Based on these data, which of the following nursing diagnosis should the nurse prioritize as the most important?
- A. Potential for infection
- B. Self care deficit
- C. Alteration in infection
- D. Fluid volume excess
Correct Answer: A
Rationale: The decreased white blood cell count (WBC) in the blood tests indicates a potential for infection. White blood cells are crucial for fighting off infections in the body. A decrease in WBC count can result in an impaired immune response, making the individual more susceptible to infections. Therefore, the nurse should prioritize the nursing diagnosis of "Potential for infection" to address the heightened risk of infection in the adult with anemia. It is important to monitor for signs and symptoms of infection, provide appropriate hygiene measures, and implement interventions to prevent infections in this individual.
You may also like to solve these questions
A 9-year-old boy develops acute myelogenous leukemia (AML) one year after completion of therapy for soft tissue sarcoma at his right thigh. Which of the following chemotherapeutic agents is MOST likely the cause of secondary acute myelogenous leukemia AML in this boy?
- A. cyclophosphamide
- B. vincristine
- C. etoposide
- D. doxorubicin
Correct Answer: C
Rationale: Etoposide is known to be associated with secondary AML due to its potential to induce chromosomal abnormalities.
Which of the ff must the nurse consider when administering IV fluids to clients with hypertension?
- A. The nurse checks the clients BP every hour
- B. The nurse checks the site and progress of the infusion every hour
- C. The nurse checks the progress of the infusion once a day
- D. The nurse checks the client's pulse rate every hour
Correct Answer: B
Rationale: When administering IV fluids to clients with hypertension, the nurse must closely monitor the site and progress of the infusion every hour to ensure proper hydration and detect any signs of complications such as infiltration or infection. Checking the blood pressure every hour, as in choice A, may not be necessary unless specifically indicated by the healthcare provider. Checking the progress of the infusion once a day, as in choice C, does not provide adequate monitoring for a client with hypertension who may be at higher risk for fluid volume overload. Checking the client's pulse rate every hour, as in choice D, is important but does not directly address the immediate monitoring needs related to the administration of IV fluids.
The nurse knows which of the following statements about TPN and peripheral parenteral nutrition is true?
- A. TPN is usually indicated for clients needing short term (less than 3 weeks) nutritional support, whereas PPN is for long term maintenance
- B. A client needing more than 3000 calories would receive PPN, whereas TPN is given to those requiring less than 3000 calories
- C. TPN is often given to those with fluid restrictions, whereas PPN is used for those without constraints on their fluid intake
- D. TPN is given to those who need to augment oral feeding, whereas PPN is used for those who are nothing by mouth
Correct Answer: C
Rationale: The statement that is true about TPN and peripheral parenteral nutrition (PPN) is that TPN is often given to those with fluid restrictions, whereas PPN is used for those without constraints on their fluid intake. This is because TPN is a hypertonic solution that can cause fluid overload if given in large volumes, so it's typically reserved for patients who have fluid restrictions. On the other hand, PPN is a less concentrated solution that can be safely administered to patients without fluid restrictions.
Biopsy is a diagnostic procedure which:
- A. Detects the presence of malignant cells
- B. Measures hemoglobin content
- C. Measures the RBC size
- D. Detects arterial occlusion Situation: Cancer ranks third in leading cause of morbidity and mortality in the Philippines. Early detection Increases the survival rate of those afflicted. You are a nurse in a cancer-prevention and screening clinic and are for health education.
Correct Answer: A
Rationale: A biopsy is a diagnostic procedure that involves the removal of a small sample of tissue or cells from the body for examination under a microscope. This is done to determine the presence of abnormal or malignant cells, which can indicate the presence of cancer or other diseases. Biopsies are often performed when there is a suspicion of cancer based on imaging studies or other clinical findings. Detecting malignant cells through a biopsy is crucial for accurate diagnosis and appropriate treatment planning. Early detection of cancer through biopsy can significantly improve the prognosis and survival rates of patients.
Mr. and Mrs. Baker's only daughter is diagnosed with heart failure. Which of the following interventions would be appropriate to promote optimal nutrition for the infant?
- A. Replacing regular nipples with easy-to-suck ones
- B. Allowing the infant to feed for at least 1 hour
- C. Providing large feedings evenly spaced every 4 hours
- D. Offering formula that is high in sodium and calories 47
Correct Answer: A
Rationale: Replacing regular nipples with easy-to-suck ones would be appropriate to promote optimal nutrition for the infant with heart failure. Infants with heart failure may have difficulty feeding due to fatigue and respiratory distress. Using easy-to-suck nipples can help the infant conserve energy during feeding and promote adequate intake. This intervention aims to make feeding easier for the infant and improve overall nutrition status.