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The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?
- A. White blood cell count.
- B. Platelet count.
- C. Red blood cell count.
- D. Hemoglobin levels.
Correct Answer: B
Rationale: Platelet count is critical as low levels cause petechiae and ecchymosis due to bleeding tendencies.
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A nurse is educating a patient with Type 2 diabetes mellitus and peripheral neuropathy. What advice should the nurse give?
- A. Shoes should be worn outside the house, but it is fine to be barefoot inside.
- B. Family members can assist with regular foot exams.
- C. Heating pads are useful if used on the lowest setting.
- D. Aching feet may be soaked in lukewarm water for one hour or more.
Correct Answer: B
Rationale: Family members assisting with regular foot exams helps detect early signs of injury or infection, critical for preventing complications in diabetic neuropathy.
A client receives a prescription for 1 liter of lactated Ringer's intravenously (IV) to be infused over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver?
- A. 100 mL/hr
- B. 125 mL/hr
- C. 150 mL/hr
- D. 175 mL/hr
Correct Answer: B
Rationale: Dividing 1000 mL by 8 hours yields 125 mL/hr, the correct infusion rate.
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?
- A. Lower back pain and hypotension.
- B. Delayed painful rash with urticaria.
- C. Acute rhinitis and nasal stuffiness.
- D. Arthritic joint changes and chronic pain.
Correct Answer: A
Rationale: Lower back pain and hypotension are indicative of an acute ABO incompatibility reaction, which can lead to severe complications like hemolysis or shock, requiring immediate reporting and intervention.
The nurse is preparing a client for discharge who was recently diagnosed with Addison's disease. Which instruction is most important for the nurse to include in this client's discharge teaching plan?
- A. Take prescribed cortisone accurately.
- B. Use a walker when weakness occurs.
- C. Avoid extreme environmental temperatures.
- D. Increase daily intake of sodium in diet.
Correct Answer: A
Rationale: Accurate cortisone administration is vital to manage Addison's disease and prevent adrenal crisis.
A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?
- A. Explain the need to limit intake of oral fluids to reduce client discomfort.
- B. Teach the client techniques for performing intermittent catheterization.
- C. Remind the client to practice pelvic floor (Kegel) exercises regularly.
- D. Provide a bedside commode for immediate use in the client's room.
Correct Answer: B
Rationale: Intermittent catheterization manages urinary retention effectively in multiple sclerosis, maintaining bladder health.