Nokea
An adult has started on continuous ambulatory peritoneal dialysis. Which nursing instruction is of highest priority?
- A. Explain the principles of osmosis and diffusion and how dialysis works
- B. Teach the client aseptic technique
- C. Plan to withhold all drugs during dialysis
- D. Encourage the client to eat a high-sodium, high-potassium diet
Correct Answer: B
Rationale: Aseptic technique is critical in peritoneal dialysis to prevent peritonitis, a serious complication. Understanding dialysis mechanics, withholding drugs, or diet are secondary.
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A 3 year-old child has tympanostomy tubes in place. The child's parent asks the nurse if he can swim in the family pool. The best response from the nurse is
- A. Your child should not swim at all while the tubes are in place.'
- B. Your child may swim in your own pool but not in a lake or ocean.'
- C. Your child may swim if he wears ear plugs.'
- D. Your child may swim anywhere.'
Correct Answer: C
Rationale: Water should not enter the ears. Children should use ear plugs when bathing or swimming and should not put their heads under the water.
Laboratory results
WBC
5000-10,000/mm³
(5-10 × 10⁹/L) 1400/mm3
(1.4 × 109/L)
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)
Female: 12-16 g/dL
(120-160 g/L) 10 g/dL
(100 g/L)
Absolute neutrophil count
2500-8000/mm³
(2.5-8 × 10⁹/L) 500/mm3
(0.5 × 109/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 3.4 mEq/L
(3.4 mmol/L)
Platelets
150,000-400,000/mm³
(150-400 × 10⁹/L) 150,000/mm3
(150 × 109/L)
A client in the hospital is receiving chemotherapy. Based on today’s blood laboratory results, which of the following actions should the nurse take?
- A. Check for hematuria
- B. Check for peaked T waves
- C. Obtain prescription for epoetin alfa
- D. Place a face mask on the client
Correct Answer: D
Rationale: Chemotherapy often causes neutropenia, increasing infection risk. A face mask (D) protects the client. Hematuria (A), peaked T waves (B), and epoetin (C) address other issues not directly indicated.
A young adult is admitted to the psychiatric unit because she has become very withdrawn and has stopped attending college classes. She sits for hours rocking back and forth and appears to be talking to someone at intervals. She does not eat or bathe or relate to others. How should the nurse approach this client upon admission?
- A. Explain the unit routines to her in detail
- B. Ask her if she has any question about the unit or what she is supposed to do
- C. Briefly explain the most essential information and then sit with her
- D. Take her by the hand and orient her to the unit
Correct Answer: C
Rationale: A withdrawn client may be overwhelmed by detailed explanations. Brief information and quiet presence build trust and reduce anxiety.
A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse?
- A. Encourage the visitor to lie down to see if symptoms change
- B. Initiate protocol to assist the visitor to the emergency department
- C. Proceed to take the visitor's blood pressure
- D. Suggest that the visitor call the health care provider
Correct Answer: B
Rationale: Sudden headache and hemibody numbness suggest a possible stroke, a medical emergency requiring immediate evaluation. Initiating protocol to transfer the visitor to the emergency department (B) ensures timely care. Lying down (A), taking blood pressure (C), or calling a provider (D) delays critical intervention.
The nurse is discussing dementia with the families of older adults. All of the following behaviors are reported. Which behavior is most suggestive of dementia?
- A. The woman can't remember the birth year of each of her six children.
- B. A woman walked to the store and got lost on the way home.
- C. A woman forgot where she put her purse.
- D. A man is wearing one green sock and one red sock and doesn't see the difference.
Correct Answer: B
Rationale: Getting lost in a familiar area indicates significant spatial disorientation, a hallmark of dementia. Forgetting details, misplacing items, or color oversight are less specific.