Nokea
The client with acute lymphocytic leukemia (ALL) is at risk for infection. What should the nurse do?
- A. Place the client in a private room.
- B. Have the client wear a mask.
- C. Have staff wear gowns and gloves.
- D. Restrict visitors.
Correct Answer: A
Rationale: Clients with ALL are immunocompromised due to neutropenia, increasing infection risk. Placing the client in a private room reduces exposure to pathogens. Masks, gowns, and visitor restrictions may be used in severe cases, but a private room is the first step.
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Initial treatment for a cerebrospinal fluid (CSF) leak after transsphenoidal hypophysectomy would most likely involve:
- A. Repacking the nose.
- B. Returning the client to surgery.
- C. Enforcing bed rest with the head of the bed elevated.
- D. Administering high-dose corticosteroid therapy.
Correct Answer: C
Rationale: Bed rest with head elevation reduces pressure on the surgical site, promoting healing of a CSF leak.
The nurse is assessing a client with anemia. In order to plan nursing care, the nurse should focus the assessment on which of the following?
- A. Decreased salivation.
- B. Bradycardia.
- C. Cold intolerance.
- D. Nausea.
Correct Answer: C
Rationale: Cold intolerance is a common symptom of anemia due to reduced oxygen-carrying capacity, and assessing it helps plan supportive care.
One goal in caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. To achieve this goal, the nurse encourages the client to:
- A. Apply heat to the extremity
- B. Elevate the legs above the heart
- C. Stop smoking
- D. Begin a jogging program
Correct Answer: C
Rationale: Stopping smoking promotes vasodilation by reducing nicotine-induced vasoconstriction and improving endothelial function, critical in arterial occlusive disease. Applying heat risks burns in ischemic tissue, elevating legs worsens arterial flow, and jogging may be contraindicated due to claudication.
To ensure safety for a hospitalized blind client, the nurse should:
- A. Require that the client has a sitter for each shift.
- B. Require that the client stays in bed until the nurse can assist.
- C. Orient the client to the room environment.
- D. Keep the side rails up when the client is alone.
Correct Answer: C
Rationale: Orienting the client to the room environment promotes safety by helping the blind client navigate the space independently and reduce the risk of falls.
A 65-year-old client is admitted to the emergency department with a fractured hip. The client has chest pain and shortness of breath. The health care provider orders nitroglycerin tablets. Which should the nurse instruct the client to do?
- A. Put the tablet under the tongue until it is dissolved.
- B. Swallow the tablet with 120 mL of water.
- C. Chew the tablet until it is dissolved.
- D. Place the tablet between his cheek and gums.
Correct Answer: A
Rationale: Sublingual nitroglycerin is administered under the tongue for rapid absorption to relieve chest pain. Other methods (swallowing, chewing, or buccal placement) are incorrect for this medication.