Nokea
The nurse is caring for a client receiving chemotherapy who is experiencing neutropenia. Which intervention would be most appropriate to recommend for inclusion in the client's plan of care?
- A. Assess the client's temperature every 4 hours due to risk of hypothermia.
- B. Instruct the client to avoid large crowds and people who are sick.
- C. Instruct the client in the use of a soft toothbrush.
- D. Assess the client for hematuria.
Correct Answer: B
Rationale: Neutropenia increases the risk of infection due to low neutrophil counts. Avoiding large crowds and sick individuals minimizes exposure to pathogens, making B the most appropriate intervention. Answer A is incorrect as hypothermia is not a primary concern. Answer C, while relevant for preventing mucosal bleeding, is less critical than infection prevention. Answer D is unrelated to neutropenia.
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A 63-year-old woman is taking digitalis, baby aspirin, potassium (K-Dur), and furosemide (Lasix) daily. She complains of multiple symptoms, which include muscle cramps and facial tics. Physical exam reveals positive Chvostek's and Trousseau's signs, hypotension, and confusion. The nurse suspects she has hypomagnesemia. What else should the nurse expect?
- A. Laboratory tests to reveal high serum calcium and potassium levels
- B. Laboratory tests to reveal low serum calcium and potassium levels
- C. Altered acid-base balance, which requires administration of NaHCO3 intravenously in addition to treatment for hypomagnesemia
- D. An order for an ECG to monitor brain function
Correct Answer: B
Rationale: Hypomagnesemia often accompanies low calcium and potassium, as seen with furosemide use, explaining symptoms like cramps and tetany.
A 20-year-old client has a cast applied for a fracture of the right femur. Three hours later, the client complains that it is hot and painful under his cast.
Which of the following is the MOST appropriate action for the nurse to take?
- A. Assess the cast for wet spots and increase air circulation in the room.
- B. Check the circulation in his casted extremity and change the client's position.
- C. Take the client's temperature and observe him for other signs of infection.
- D. Medicate the client for pain and notify the physician of his complaint.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) heat is sign of pressure (2) correct-heat is sign of pressure, pressure limits circulation (3) too early to see signs of infection (4) all complaints must be investigated, medication would mask signs of pressure, assessment first step
The nurse is caring for a client who is postoperative day 1 after a lumbar laminectomy. Which of the following actions is the PRIORITY?
- A. Encourage the client to log-roll when turning.
- B. Administer pain medication as needed.
- C. Monitor the surgical drain for output.
- D. Check the incision for redness.
Correct Answer: A
Rationale: Encouraging log-rolling is the priority to prevent spinal strain and maintain alignment post-lumbar laminectomy. Options B, C, and D are important but secondary: pain management, drain monitoring, and incision checks follow proper positioning.
A client with multiple sclerosis.
The nurse is performing discharge teaching on a client with multiple sclerosis. It is MOST important for the nurse to include which of the following instructions?
- A. Ambulate as tolerated every day.
- B. Avoid overexposure to heat or cold.
- C. Perform stretching and strengthening exercises.
- D. Participate in social activities.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is encouraged to ambulate as tolerated (2) correct-overexposure to heat or cold may cause damage related to the changes in sensation (3) client is encouraged to participate in an exercise program to include ROM, stretching, and strengthening exercises (4) client is encouraged to continue usual activities as much as possible, including social activities
The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time?
- A. Daily needs and concerns
- B. The overview cardiac rehabilitation
- C. Medication and diet guideline
- D. Activity and rest guidelines
Correct Answer: A
Rationale: At 2 days post-MI, the client's education should be focused on the immediate needs and concerns for the day.