Nokea
The nurse checks the lab values of a newly admitted client. RBC: 4.0 million/mm³, WBC: 1500/mm³, Platelets: 40,000/mm³. What nursing actions are indicated because of these lab values?
- A. Keep the client on bed rest and protective isolation.
- B. Plan for protective isolation and do not give injections.
- C. Keep the client on bed rest and avoid trauma.
- D. There are no special nursing actions indicated.
Correct Answer: B
Rationale: Low WBC (neutropenia) requires protective isolation, and low platelets (thrombocytopenia) contraindicate injections to prevent bleeding and infection.
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The nurse is talking with a client who has human immunodeficiency virus (HIV). Which of the following statements by the client would indicate a correct understanding of the condition? Select all that apply.
- A. I should receive the influenza vaccine every year
- B. I will ask my roommate to clean the cat litter box for me
- C. I should ask for my steak to be cooked thoroughly with no pink inside
- D. I can eat the raw vegetables I grew in my garden if my HIV viral load is undetectable
- E. I will use bottled water when brushing my teeth if I travel to an area with poor sanitation
Correct Answer: A,B,C,E
Rationale: Flu vaccine, avoiding cat litter (toxoplasmosis risk), thorough cooking, and bottled water in unsanitary areas reduce infection risk in HIV. Raw vegetables pose a risk, even with undetectable viral load.
A client with suspected foot osteomyelitis is scheduled for an MRI. Which client findings should the nurse report before the test? Select all that apply.
- A. Cardiac pacemaker
- B. Colostomy
- C. Retained metal foreign body in eye
- D. Total hip replacement
- E. Transdermal testosterone patch
Correct Answer: A,C,D
Rationale: Pacemakers, metal in the eye, and hip replacements pose MRI risks due to magnetic interference or heating. Colostomies and transdermal patches are not contraindicated for MRI.
A diabetic client asks the nurse why she should use a diaphragm as a method of contraception instead of birth control pills. The best explanation for the use of a diaphragm is:
- A. A diaphragm will best prevent pregnancy because oral contraceptives are rendered ineffective by increased glucose levels.
- B. A diaphragm is a noninvasive method of contraception that will not alter the blood glucose levels.
- C. A diaphragm will provide intrauterine contraception by preventing implantation of the embryo.
- D. A diaphragm is a noninvasive method of contraception that prevents the egg from being released from the ovary.
Correct Answer: B
Rationale: A diaphragm does not affect blood glucose, unlike oral contraceptives, which can alter glycemic control. Oral contraceptives are not ineffective due to glucose levels, diaphragms do not prevent implantation or ovulation, and they are not intrauterine.
The nurse is teaching a client about newly prescribed amlodipine. Which adverse effect would be most important for the nurse to include?
- A. Depression
- B. Dizziness
- C. Dry cough
- D. Erectile dysfunction
Correct Answer: B
Rationale: Dizziness, due to amlodipine’s vasodilatory effect, is a common and critical side effect, risking falls, especially in the elderly. Depression, cough, and erectile dysfunction are less common or associated with other drugs.
The nurse is contributing to a staff education program about assessing the urinary system. Which statement by a nurse would indicate a correct understanding of the program?
- A. The bladder should be nontender and nonpalpable when it is empty
- B. Dark brown urine may indicate that the client has a urinary tract infection
- C. I should be able to palpate both kidneys regardless of the client’s abdominal girth
- D. I will assess for tenderness of the kidneys by performing blunt percussion over the client’s lower abdomen
Correct Answer: A
Rationale: An empty bladder is nontender and nonpalpable, indicating correct understanding. Dark brown urine suggests dehydration or other issues, not UTI; kidneys are not always palpable; and percussion is over the costovertebral angle, not lower abdomen.