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The nurse is assisting with a bone marrow aspiration and biopsy. In which order, from first to last, should the nurse complete the following tasks?
- A. Verify the client has signed an informed consent.
- B. Position the client in a side-lying position.
- C. Clean the skin with an antiseptic solution.
- D. Apply ice to the biopsy site.
Correct Answer: C,A,B,D
Rationale: First, the nurse must verify that the client has voluntarily signed a consent form before the procedure begins, and check that the client understands the procedure. The nurse then positions the client in a side-lying, or lateral decubitus, position with the affected side up. Then the nurse should clean the skin site and surrounding area with an antiseptic solution such as Betadine before the health care provider collects the specimen. When the procedure is finished, the nurse must apply ice to the biopsy site to reduce pain.
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Several clients who work in the same building are brought to the emergency department. They all common to the patient's condition. Including fever, headache, a rash over the entire body, and abdominal pain with vomiting and diarrhea. Upon initial assessment, the nurse finds that each client has low blood pressure and has developed petechiae in the area where the blood pressure cuff was inflated. Which isolation precautions should the nurse initiate?
- A. Contact isolation with double-gloving and shoe covers.
- B. Respiratory isolation with positive pressure rooms.
- C. Enteric precautions.
- D. Reverse isolation.
Correct Answer: A
Rationale: Symptoms suggest a hemorrhagic fever (e.g., Ebola), requiring contact isolation with enhanced precautions like double-gloving and shoe covers to prevent transmission.
A 15-year-old client needs life-saving emergency surgery, but his relatives live an hour away from the hospital and cannot sign the consent form. What is the nurse's best response?
- A. Send the client to surgery without the consent.
- B. Call the family for a consent over the telephone and have another nurse listen as a witness.
- C. No action is necessary in this case because consent is not needed.
- D. Have the family sign the consent form as soon as they arrive.
Correct Answer: B
Rationale: For life-saving emergency surgery in a minor, telephone consent from the family with a witness is acceptable to meet legal requirements while expediting care.
A client who weighs 187 lb has an order to receive enoxaparin (Lovenox) 1 mg/kg. This drug is available in a concentration of 30 mg/0.3 mL. What dose would the nurse administer in milliliters?
- A. 0.85 mL
- B. 0.9 mL
- C. 0.95 mL
- D. 1.0 mL
Correct Answer: A
Rationale: Calculation: 187 lb ÷ 2.2 = 85 kg. Dose = 85 kg × 1 mg/kg = 85 mg. Concentration = 30 mg/0.3 mL = 100 mg/mL. Volume = 85 mg ÷ 100 mg/mL = 0.85 mL. Thus, the nurse administers 0.85 mL.
The nurse assesses that the client with hepatitis is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. Based on this information, which of the following would be an appropriate nursing diagnosis?
- A. Impaired physical mobility related to malaise.
- B. Self-care deficit related to fatigue.
- C. Ineffective coping related to long-term illness.
- D. Activity intolerance related to fatigue.
Correct Answer: D
Rationale: Activity intolerance related to fatigue (D) accurately reflects the client's rapid tiring due to hepatitis. Impaired mobility (A), self-care deficit (B), and ineffective coping (C) are less directly supported by the symptoms described.
A client with osteoarthritis asks about dietary changes to manage symptoms. Which recommendation is most appropriate?
- A. Increase intake of red meat.
- B. Consume foods rich in omega-3 fatty acids.
- C. Avoid all dairy products.
- D. Limit fruit consumption.
Correct Answer: B
Rationale: Omega-3 fatty acids have anti-inflammatory properties, helping manage osteoarthritis symptoms.