Nokea
The nurse is caring for a client with a history of breast cancer who is receiving chemotherapy. Which of the following laboratory values should the nurse monitor closely?
- A. White blood cell count.
- B. Blood glucose levels.
- C. Serum potassium.
- D. Hemoglobin A1c.
Correct Answer: A
Rationale: Chemotherapy can cause bone marrow suppression, requiring close monitoring of white blood cell counts for infection risk.
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The nurse understands that the client is responding favorably to a prescription for colchicine when there is a decrease in which sign/symptom?
- A. Headaches
- B. Joint inflammation
- C. Blood glucose level
- D. Serum triglyceride level
Correct Answer: B
Rationale: Colchicine is classified as an antigout agent. It interferes with the ability of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client should report a decrease in pain and inflammation in affected joints, as well as a decrease in the number of gout attacks. The other options are not related to the use of this medication.
The nurse is performing Leopold's maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown by the following maneuvers is the nurse performing?
- A. First maneuver.
- B. Second maneuver.
- C. Third maneuver.
- D. Fourth maneuver.
Correct Answer: C
Rationale: The third Leopold's maneuver involves palpating the lower uterus to determine the presenting part, typically performed in the eighth month to assess fetal position.
Which nursing action is most essential for the hospitalized client with a new tracheostomy?
- A. Decrease secretions
- B. Provide client teaching regarding tracheostomy care
- C. Relieve anxiety related to the tracheostomy
- D. Maintain a patent airway
Correct Answer: D
Rationale: Maintaining a patent airway is the most critical action for a client with a new tracheostomy to ensure adequate oxygenation. Other actions are important but secondary to airway patency.
The nurse is preparing to provide preoperative teaching with a client scheduled for radical neck dissection. Which topic should the nurse initially focus on?
- A. The client's usual coping behaviors
- B. The client's dependable support systems
- C. Postoperative communication techniques
- D. The information already supplied by the surgeon
Correct Answer: D
Rationale: The first step in client education is establishing what the client already knows. This allows the nurse to correct any misinformation or misunderstandings, determine the starting point for teaching, and plan and implement the education at the client's level. Although the remaining options can be a component of the plan, the first step in client education is establishing what the client already knows.
The nurse is planning discharge care with the parents of a 16-year-old boy who recently attempted suicide. The nurse should advise the parents to tell the nurse if their son:
- A. Expresses a desire to date.
- B. Decides to try out for an extracurricular activity.
- C. Gives away valued personal items.
- D. Desires to spend more time with his friends.
Correct Answer: C
Rationale: Giving away valued items is a warning sign of suicidal intent, requiring immediate reporting. The other behaviors are normal adolescent activities.