Nokea
The nurse is caring for a client with a history of leukemia.
- A. Which laboratory finding is most concerning for a client with leukemia?
- B. White blood cell count of 50,000/mm³.
- C. Platelet count of 20,000/mm³.
- D. Hemoglobin of 11.0 g/dL.
- E. Serum potassium of 4.0 mEq/L.
Correct Answer: B
Rationale: A platelet count of 20,000/mm³ indicates severe thrombocytopenia, risking life-threatening bleeding in leukemia. Elevated WBC is expected, low hemoglobin is common, and normal potassium is unremarkable.
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Several days after a client had a myocardial infarction, the physician placed him on a 2-gm sodium diet.
Which of the following selections would indicate to the nurse an understanding of the diet?
- A. Scrambled egg, orange slices, and milk.
- B. Instant oatmeal, toast, and orange juice.
- C. Poached egg, bacon, and milk.
- D. Biscuit, fruit cup, and sausage.
Correct Answer: A
Rationale: Strategy: Determine the foods that are allowed on a 2-gm sodium diet. (1) correct-all items are low in sodium; milk is allowed on a salt-restricted diet (2) instant oatmeal has sodium added (3) bacon is high in sodium (4) all baked breads are high in sodium, as is sausage
The nurse is caring for a client who is postoperative day 1 after a thyroidectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Calcium level of 8.0 mg/dL.
- B. Temperature of 99.5°F (37.5°C).
- C. Heart rate of 100 bpm.
- D. Pain at the incision site.
Correct Answer: A
Rationale: A calcium level of 8.0 mg/dL indicates hypocalcemia, a serious complication post-thyroidectomy due to parathyroid damage, risking tetany or seizures. Options B, C, and D are expected: slight fever, tachycardia, and incision pain are common postoperatively.
The nurse is caring for clients in outpatient surgery.
- A. What is the best statement by the nurse to the mother of a four-year-old preparing for eye surgery?
- B. Draw a picture of the eye to explain what will happen.'
- C. Tell your daughter that the procedure will take one hour.'
- D. Use dolls or puppets to explain how to get ready for surgery.'
- E. Read an age-appropriate illustrated book about eye surgery to your daughter.'
Correct Answer: C
Rationale: For a four-year-old, using dolls or puppets to demonstrate the procedure in simple terms is developmentally appropriate, addressing what the child will experience (see, hear, feel). Drawing pictures or reading books is better for school-aged children, and time concepts like one hour are not relatable to preschoolers.
The nasogastric tube of a post-op gastrectomy client has stopped draining greenish liquid. The nurse should
- A. Irrigate it as ordered with distilled water
- B. Irrigate it as ordered with normal saline
- C. Check for kinking or obstruction
- D. Withdraw the tube several inches and reposition it
Correct Answer: B
Rationale: Irrigate it as ordered with normal saline. Nasogastric tubes are only irrigated with normal saline to maintain patency.
The nurse is caring for a client who has right-sided weakness and has been told to use a cane for walking. Which action by the client indicates that he can use a cane correctly?
- A. He holds the cane in his right hand and moves the cane with the right leg when walking.
- B. He moves the cane from hand to hand when walking.
- C. He carries the cane in his left hand and moves it at the same time he moves his right foot.
- D. He puts the cane forward and then moves the left foot forward followed by the right foot.
Correct Answer: C
Rationale: Holding the cane in the left (unaffected) hand and moving it with the right (weak) leg provides support, indicating correct use.