Nokea
The client is admitted with a diagnosis of acute leukemia. Which nursing intervention is the priority?
- A. Administering pain medication
- B. Preventing infection
- C. Monitoring blood glucose levels
- D. Encouraging high-fiber foods
Correct Answer: B
Rationale: Acute leukemia causes immunosuppression, making infection prevention (e.g., hand hygiene, protective isolation) the priority to avoid life-threatening complications. Pain, glucose, and diet are secondary.
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A client presents to the psychiatric unit crying hysterically. She is diagnosed with severe anxiety disorder. The first nursing action is to:
- A. Demand that she relax
- B. Ask what is the problem
- C. Stand or sit next to her
- D. Give her something to do
Correct Answer: C
Rationale: Standing or sitting next to the client conveys caring and provides a sense of security, reducing anxiety.
A client with a head injury has an order for dexamethasone (Decadron) 10 mg IV; push every 6 hours. The dose is available Decadron 4 mg/mL. How much will the nurse administer?
- A. mL(s)
Correct Answer: 2.5 mL
Rationale: Dose: 10 mg ÷ 4 mg/mL = 2.5 mL.
A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin. The nurse's first intervention should be to:
- A. Check FHT
- B. Notify the attending physician
- C. Turn off the IV oxytocin
- D. Prepare for the delivery because the client is probably in transition
Correct Answer: C
Rationale: FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. The physician should be notified, but this is not the first intervention the nurse should do. The standard of care for an induction according to the Association of Women's Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. Contractions lasting 60-90 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.
The nurse is performing an assessment on a client with a history of pancreatitis. Which finding is most concerning?
- A. Abdominal tenderness
- B. Nausea and vomiting
- C. Fever of 101°F
- D. Grey-Turner’s sign
Correct Answer: D
Rationale: Grey-Turner’s sign (flank bruising) indicates retroperitoneal hemorrhage in pancreatitis, a life-threatening complication requiring immediate attention. Other findings are common but less severe.
A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate?
- A. Put in a nasogastric tube and lavage the child's stomach.
- B. Monitor muscular status.
- C. Teach mother poison prevention techniques.
- D. Place child on respiratory assistance.
Correct Answer: A
Rationale: The immediate treatment for drug overdose is removal of the drug from the stomach by either forced emesis or gastric lavage. The child's unconscious state prohibits forced emesis. Toxic amounts of salicylates directly affect the respiratory system, which could lead to respiratory failure. The mother's anxiety is probably so high that preventive guidance will be ineffective. Respiratory assistance is not needed if the child's respiratory function is unaltered.