Nursing Process Test Bank

Nursing Process Test Bank Related

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For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care?

  • A. Administering aspirin if the temperature exceeds 102○1 F (38.8○0 C)
  • B. inspecting the skin for petechiae once every shift
  • C. providing for frequent rest periods
  • D. Placing the client in strict isolation
Correct Answer: C

Rationale: The correct answer is C: providing for frequent rest periods. This intervention is essential for a client with radiation-induced thrombocytopenia to prevent further platelet depletion and reduce the risk of bleeding episodes. Rest periods help conserve energy and minimize physical exertion, which can trigger bleeding in thrombocytopenic clients.

Rationale:
1. Administering aspirin (choice A) is contraindicated in thrombocytopenia as it can further decrease platelet count and increase the risk of bleeding.
2. Inspecting the skin for petechiae (choice B) is important but not as crucial as providing rest periods in managing thrombocytopenia.
3. Placing the client in strict isolation (choice D) is not necessary for radiation-induced thrombocytopenia unless there are other specific infectious concerns.

In summary, providing frequent rest periods is the most appropriate intervention to manage radiation-induced thrombocytopenia, promoting patient

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The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?

  • A. The patient’s room with the door closed
  • B. The waiting area with the television turned off
  • C. The patient’s room before administration of pain medication
  • D. The waiting room while the occupational therapist is working on leg exercises
Correct Answer: B

Rationale: The correct answer is B: The waiting area with the television turned off. This choice eliminates potential distractions, allowing the patient with a hearing deficit to focus on the interview. Noise from the television can interfere with communication. Other choices are incorrect because: A) The closed door may block out external noise, but the patient's room could still have distractions. C) Administering pain medication can affect the patient's alertness and ability to communicate effectively. D) The waiting room with occupational therapy activities can be noisy and distracting. Conducting the interview in a quiet waiting area ensures optimal communication and understanding.

The nurse is instructing a client with newly diagnosed hypoparathyroidism about the regimen used to treat this disorder. The nurse should state that the physician probably will prescribe daily supplements of calcium and:

  • A. Folic acid
  • B. Potassium
  • C. Vitamin D
  • D. Iron
Correct Answer: C

Rationale: The correct answer is C: Vitamin D. In hypoparathyroidism, there is a deficiency of parathyroid hormone leading to low calcium levels. Vitamin D helps in the absorption of calcium from the intestines, thus aiding in maintaining normal calcium levels. It is often prescribed along with calcium supplements to support bone health and prevent complications. Folic acid (A) is not directly related to the treatment of hypoparathyroidism. Potassium (B) is not typically prescribed for this condition and can be harmful in high levels. Iron (D) is not directly involved in calcium metabolism and is not part of the standard treatment regimen for hypoparathyroidism.

When teaching a client about insulin therapy, the nurse should instruct the client to avoid which over-the- counter preparation that can interact with insulin?

  • A. Antacids
  • B. Vitamins with irons
  • C. Acetaminophen preparations
  • D. Salicylate preparations
Correct Answer: D

Rationale: The correct answer is D: Salicylate preparations. Salicylate can potentiate the effects of insulin, leading to hypoglycemia. Therefore, the nurse should instruct the client to avoid this over-the-counter preparation when on insulin therapy. Antacids (A), vitamins with iron (B), and acetaminophen preparations (C) do not typically interact with insulin in a significant way.

Which of the following statements about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?

  • A. Administer 2 to 3L of IV fluid rapidly
  • B. Administer 6L of IV fluid over the first 24 hours
  • C. Administer a dextrose solution containing normal saline solution
  • D. Administer IV fluid slowly to prevent circulatory overload and collapse
Correct Answer: D

Rationale: The correct answer is D because in HHNS, the primary goal is to gradually correct dehydration without causing fluid overload. Administering IV fluid slowly helps prevent circulatory overload and collapse. Choice A is incorrect as rapid administration can lead to fluid overload and electrolyte imbalances. Choice B is incorrect as 6L over 24 hours is excessive and can cause fluid overload. Choice C is incorrect as dextrose solution with normal saline is not the ideal fluid replacement for this condition.

The nurse, in assessing the adequacy of a client's fluid replacement during the first 2 to 3 days following full- thickness burns to the trunk and right thigh, would be aware that the most significant data would be obtained from recording

  • A. Weights every day .
  • B. Blood pressure every 15 minutes
  • C. Urinary output every hour
  • D. Extent of peripheral edema every 4 hours
Correct Answer: C

Rationale: The correct answer is C: Urinary output every hour. This is because assessing urinary output is crucial for monitoring fluid balance in burn patients. Adequate urine output indicates proper fluid replacement, while decreased output may indicate dehydration. Recording weights daily (choice A) may be important but not as immediate and specific as urinary output. Blood pressure every 15 minutes (choice B) is too frequent and not directly related to fluid replacement in this context. Monitoring peripheral edema every 4 hours (choice D) is not as reliable as urinary output for assessing fluid status.

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