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The nurse is assisting with the admission of a client who had a nephrectomy 6 hours ago. The client should be assigned to a semiprivate room with a client who has
- A. a pulmonary embolism, is receiving heparin therapy, and has a decreased platelet count
- B. cellulitis of the leg, is receiving antibiotic therapy, and is reporting loose stools
- C. type 1 diabetes mellitus, a wound on the foot, and an elevated temperature
- D. HIV infection, a decreased CD4+ cell count, and is reporting fatigue
Correct Answer: B
Rationale: The client with cellulitis and loose stools is least likely to pose an infection risk to the post-nephrectomy client, who is at risk for infection due to recent surgery. Other options involve conditions with higher infection risks or bleeding concerns.
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The nurse is caring for a 5-year-old client with sickle cell disease who is experiencing an episode of acute pain. The client has shortness of breath, nausea with vomiting, and severe generalized body and joint pain. Which of the following findings requires immediate intervention?
- A. enlarged spleen on palpation
- B. hemoglobin level of 9.0 g/dL (90 g/L)
- C. bilateral swelling of the hands and feet
- D. pain rated as 8 on the Wong-Baker FACES Scale
Correct Answer: A
Rationale: An enlarged spleen may indicate splenic sequestration, a life-threatening complication requiring immediate intervention.
As a general guide for emergency management of acute alcohol intoxication, it is important for the nurse initially to obtain data regarding which of the following?
- A. What and how much the client drinks, according to family and friends
- B. The blood alcohol level of the client
- C. The blood pressure level of the client
- D. The blood glucose level of the client
Correct Answer: B
Rationale: Blood alcohol levels are generally obtained to determine the level of intoxication. The amount of alcohol consumed determines how much medication the client needs for detoxification and treatment. Reports of alcohol consumption are notoriously inaccurate.
A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the provider ordering
- A. pulmonary embolectomy
- B. vena caval interruption
- C. increasing the Coumadin therapy to an INR of 3-4
- D. thrombolytic therapy
Correct Answer: B
Rationale: vena caval interruption. Clients with contraindications to Heparin, recurrent PE or those with complications related to the medical therapy may require vena caval interruption by the placement of a filter device in the inferior vena cava. A filter can be placed transvenously to trap clots before they travel to the pulmonary circulation.
A client is on a low-residue diet. All of the following are on the client's tray. Which should be removed?
- A. Roast beef
- B. Mashed potato
- C. Strawberry jam
- D. White bread
Correct Answer: C
Rationale: Strawberry jam contains seeds, which increase intestinal residue, contraindicated in a low-residue diet. Roast beef, mashed potatoes, and white bread are low-fiber and appropriate.
The nurse is talking about diaper changes with a client who is 48 hours postpartum. The client states, 'I cannot change my baby's diaper as well as you can. Will you change it for me?' Which of the following responses would be appropriate for the nurse to make?
- A. Changing your baby's diaper now is important for the bonding process.
- B. I will stay at your bedside and watch while you change your baby's diaper.
- C. It is more important for you to take care of yourself now, so I will change your baby's diaper.
- D. It is time that you change your baby's diaper because you will have to do it by yourself after discharge.
Correct Answer: B
Rationale: Supporting the client while they change the diaper builds confidence and promotes independence.