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The nurse is caring for a client who is terminally ill. When the client dies, the nurse should:
- A. Pronounce the client dead and call the doctor.
- B. Contact the coroner.
- C. Tag the body prior to the funeral home notification.
- D. Request an autopsy.
Correct Answer: C
Rationale: Tagging the body ensures proper identification before transfer to the funeral home. Nurses do not pronounce death, coroner contact depends on policy, and autopsies are not routinely requested.
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A client with cancer received platelet infusions 24 hours ago. Which of the following assessment findings would indicate the most therapeutic effect from the transfusions?
- A. An Hgb level decrease from 8.9 to 8.7
- B. A temperature reading of 99.4
- C. A white blood cell count of 11,000
- D. A decrease in oozing of blood from the IV site
Correct Answer: D
Rationale: Platelets deal with the clotting of blood. Lack of platelets can cause bleeding. Answers A, B, and C do not directly relate to platelets, so they are incorrect.
A nurse from the float pool is giving medications on a pediatric unit and is to give medications to a 2-year-old child in room 534, bed B. The child in that room does not have an identification band. What is the best action for the nurse to take?
- A. Ask the child what his name is
- B. Give the medication to the child in room 534, bed B
- C. Refuse to give the medication
- D. Ask the adults beside the bed the name of the child in that bed
Correct Answer: C
Rationale: Refusing to give medication without proper identification ensures safety, as a 2-year-old cannot reliably confirm identity.
The nurse in the outpatient clinic is caring for a client with heart failure who reports increased ankle swelling and a 3-lb (1.4-kg) weight gain over the past 2 days. The nurse reviews the client's current medications and anticipates the need for an increase in the dosage of which of the following medications?
- A. Bumetanide
- B. Candesartan
- C. Carvedilol
- D. Isosorbide
Correct Answer: A
Rationale: A 3-lb weight gain and ankle swelling in heart failure indicate fluid retention, requiring an increased dose of a diuretic like bumetanide . Candesartan , carvedilol , and isosorbide manage other aspects but do not directly address acute fluid overload.
An older adult client is to receive an antibiotic, gentamicin. What diagnostic finding indicates the client may have difficulty excreting the medication?
- A. High gastric pH
- B. High serum creatinine
- C. Low serum albumin
- D. Low serum blood urea nitrogen
Correct Answer: B
Rationale: An elevated serum creatinine indicates reduced renal function. Reduced renal function will delay the excretion of many medications.
A client who has congestive heart failure is being admitted. How should the nurse position this client?
- A. Supine
- B. Sims'
- C. Semi-sitting
- D. Side-lying
Correct Answer: C
Rationale: Semi-sitting (Fowler's position) reduces cardiac workload and improves breathing in congestive heart failure by decreasing venous return.