Nokea
The complete blood count of a client admitted with anemia reveals that the red blood cells are hypochromic and microcytic. The nurse recognizes that the client has:
- A. Aplastic anemia
- B. Iron-deficiency anemia
- C. Pernicious anemia
- D. Hemolytic anemia
Correct Answer: B
Rationale: Hypochromic, microcytic red blood cells are characteristic of iron-deficiency anemia, caused by insufficient iron for hemoglobin synthesis.
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A client on the postpartum unit has a proctoepisiotomy. The nurse should anticipate administering which medication?
- A. Dulcolax suppository
- B. Docusate sodium (Colace)
- C. Methyergonovine maleate (Methergine)
- D. Bromocriptine sulfate (Parlodel)
Correct Answer: B
Rationale: Docusate sodium (Colace) is a stool softener, appropriate to prevent straining and promote healing after a proctoepisiotomy.
The physician has ordered aerosol treatments, chest percussion, and postural drainage for a client with cystic fibrosis. The nurse recognizes that the combination of therapies is to:
- A. Decrease respiratory effort and mucous production
- B. Increase efficiency of the diaphragm and gas exchange
- C. Dilate the bronchioles and help remove secretions
- D. Stimulate coughing and oxygen consumption
Correct Answer: C
Rationale: These therapies aim to dilate airways (via aerosols) and mobilize thick mucus (via percussion and drainage) to improve breathing in cystic fibrosis.
The nurse is assessing a newborn in the well-baby nursery. Which finding should alert the nurse to the possibility of a cardiac anomaly?
- A. Diminished femoral pulses
- B. Harlequin's sign
- C. Circumoral pallor
- D. Acrocyanosis
Correct Answer: A
Rationale: Diminished femoral pulses suggest coarctation of the aorta, a cardiac anomaly, requiring further evaluation.
The nurse is preparing to suction the client with a tracheotomy. The nurse notes a previously used bottle of normal saline on the client's bedside table. There is no label to indicate the date or time of initial use. The nurse should:
- A. Lip the bottle and use a pack of sterile 4x4 for the dressing
- B. Obtain a new bottle and label it with the date and time of first use
- C. Ask the ward secretary when the solution was requested
- D. Label the existing bottle with the current date and time
Correct Answer: B
Rationale: Using an unlabeled, previously opened saline bottle risks contamination; a new, labeled bottle ensures sterility.
An adolescent client hospitalized with anorexia nervosa is described by her parents as 'the perfect child.' When planning care for the client, the nurse should:
- A. Allow her to choose what foods she will eat
- B. Provide activities to foster her self-identity
- C. Encourage her to participate in morning exercise
- D. Provide a private room near the nurse's station
Correct Answer: B
Rationale: Activities fostering self-identity address the underlying issues of low self-esteem and perfectionism common in anorexia nervosa.