Nokea
Four clients are admitted to a medical unit. If only one private room is available, it should be assigned to:
- A. The client with ulcerative colitis
- B. The client with neutropenia
- C. The client with cholecystitis
- D. The client with polycythemia vera
Correct Answer: B
Rationale: Neutropenia increases infection risk, so a private room minimizes exposure to pathogens.
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A child was exposed to the hepatitis A virus, became ill, and made a full recovery 2 years ago. The child is now immune to the hepatitis A virus and will likely be protected for the rest of her life. This type of immunity is referred to as
- A. active artificial immunity.
- B. naturally acquired active immunity.
- C. artificially acquired passive immunity.
- D. naturally acquired passive immunity.
Correct Answer: B
Rationale: Recovery from hepatitis A infection confers lifelong immunity via naturally acquired active immunity, as the body produces its own antibodies.
The nurse is caring for a client with depression over the recent death of her father from cancer. The client states, 'It's my fault. I should have insisted he get regular checkups instead of letting him put it off.' The nurse responds, 'You feel like it's your fault?' Which therapeutic communication technique is the nurse using?
- A. exploring
- B. reflecting
- C. restating
- D. focusing
Correct Answer: B
Rationale: Reflecting mirrors the client’s feelings, encouraging further expression and exploration of emotions.
When administering a capsule that is individually wrapped to a client, when should the wrapping be removed?
- A. When initially obtained from the medicine cart
- B. When placed in the medicine cup
- C. Prior to entering the client's room
- D. At bedside in the client's presence
Correct Answer: D
Rationale: Removing the wrapping at the bedside (D) ensures the client sees the medication, enhancing safety and trust.
A client has immune thrombocytopenic purpura. The client's platelet count is 19,000. Which initial treatment does the nurse expect?
- A. Splenectomy
- B. Immunosuppressive therapy
- C. Observation only
- D. Platelet administration
Correct Answer: B
Rationale: For ITP with a platelet count of 19,000, immunosuppressive therapy (B), like corticosteroids, is typically initial to increase platelet production. Splenectomy (A) is later, observation (C) is risky, and platelets (D) are less effective.
The client is having fetal heart rates of 100-110 beats per minute during the contractions. The first action the nurse should take is to:
- A. Apply an internal monitor
- B. Turn the client to her side
- C. Get the client up and walk her in the hall
- D. Move the client to the delivery room
Correct Answer: B
Rationale: Turning the client to her side improves uteroplacental perfusion, addressing fetal bradycardia during contractions.