Nokea
The nurse identifies deficient knowledge when the client undergoing induction therapy for leukemia makes which of the following statements?
- A. I will have to pace my activities with rest periods.'
- B. I can't wait to get home to my cat!'
- C. I will use warm saline gargle instead of brushing my teeth.'
- D. I must report a temperature of 100°F.'
Correct Answer: B
Rationale: During leukemia induction therapy, the client is at high risk for infection due to neutropenia. Pets like cats can carry pathogens (e.g., Toxoplasma), and the statement about returning to a cat indicates a knowledge deficit about infection risks. The other statements reflect appropriate self-care measures.
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A priority nursing diagnosis for an adult female who has pruritus and is continuously scratching the affected areas and demonstrates agitation and anxiety regarding the itching sensation would be:
- A. Risk for infection related to pruritus.
- B. Ineffective health maintenance related to lack of knowledge of the disease process.
- C. Unsporced skin integrity related to dehydration from the treatment medications.
- D. Social isolation related to poor self-image.
Correct Answer: A
Rationale: Scratching due to pruritus increases the risk of skin breakdown and infection, making this the priority nursing diagnosis.
Which lab result indicates worsening acute renal failure?
- A. Creatinine 3.5 mg/dL.
- B. BUN 20 mg/dL.
- C. Potassium 4.0 mEq/L.
- D. Sodium 140 mEq/L.
Correct Answer: A
Rationale: Elevated creatinine indicates reduced kidney function in acute renal failure.
A client complaining of numbness from the back of his left buttock to the dorsum of his foot and big toe is scheduled to undergo a laminectomy. The operative consent form states, 'a left lumbar laminectomy of L3-4.' Which of the following should the nurse do next?
- A. Have the client sign the consent form.
- B. Call the surgeon.
- C. Change the consent form.
- D. Review the client's history.
Correct Answer: B
Rationale: The consent form must match the client's symptoms, which suggest L5-S1 involvement, not L3-4. The surgeon must clarify.
A client has a positive reaction to the Mantoux test. The nurse correctly interprets this reaction to mean that the client has:
- A. Active tuberculosis.
- B. Had contact with Mycobacterium tuberculosis.
- C. Developed a resistance to tubercle bacilli.
- D. Developed passive immunity to tuberculosis.
Correct Answer: B
Rationale: A positive Mantoux test indicates exposure to Mycobacterium tuberculosis, not necessarily active disease. It does not imply resistance or passive immunity.
A client is receiving dopamine hydrochloride for treatment of shock. The nurse should:
- A. Administer pain medication concurrently.
- B. Monitor blood pressure continuously.
- C. Evaluate arterial blood gases at least every 2 hours.
- D. Monitor for signs of infection.
Correct Answer: B
Rationale: Dopamine can cause significant changes in blood pressure due to its inotropic and vasopressor effects. Continuous blood pressure monitoring is essential to titrate the dose and prevent complications. Pain medication, arterial blood gases, and infection monitoring are not primary.