Nokea
The nurse is caring for a client with a platelet count of 18,000 mm3 [150,000-400,000 mm3]. What is the priority action the nurse should take?
- A. Review the client's most recent liver function tests.
- B. Educate the client to notify staff before getting out of bed.
- C. Obtain and monitor the client's temperature.
- D. Encourage the client to turn, cough, and deep breathe.
Correct Answer: B
Rationale: Severe thrombocytopenia (18,000 mm3) (B) risks bleeding, so educating the client to notify staff before moving prevents injury. Liver tests (A), temperature (C), and respiratory exercises (D) are secondary to immediate safety measures.
You may also like to solve these questions
The nurse in the emergency department (ED) is assessing a client involved in a motor vehicle crash who sustained a penetrating abdominal trauma. The client’s vital signs are: T 97.5°F (36.4°C); P 108 bpm; RR 22; BP 98/64 mm Hg; pulse oximetry 94% on room air. Which of the following actions should the nurse take first?
- A. Prepare the client for surgery.
- B. Insert a nasogastric (NG) tube.
- C. Auscultate the client’s bowel sounds.
- D. Reassess vital signs.
Correct Answer: D
Rationale: Reassessing vital signs (D) is the first action to confirm stability or deterioration in a client with penetrating abdominal trauma and tachycardia/hypotension, guiding further interventions. Surgery prep (A), NG tube (B), and bowel sounds (C) follow reassessment.
The nurse is planning client care assignments. Which task should be delegated to the unlicensed assistive personnel (UAP)?
- A. The initial ambulation of a client following a laparoscopic hernia repair.
- B. Feed a client who has dysphagia.
- C. Applying sequential compression devices to a client’s lower extremities.
- D. Calling in prescriptions to the local pharmacy for a client ready for discharge.
Correct Answer: C
Rationale: Applying sequential compression devices (C) is a non-clinical task within the UAP’s scope. Initial ambulation (A), feeding with dysphagia (B), and calling prescriptions (D) require clinical judgment or RN/LPN skills due to risk or complexity.
The Unlicensed Assistive Personnel (UAP) is helping a female patient with early ambulation postsurgery. The CNA has just applied a gait belt to the patient's waist. Which of the following actions by the CNA will need interference and correction by the supervising nurse?
- A. Holding onto the belt's outer edge or center, preventing the patient from leaning or drooping to one side.
- B. Pulling from the front of the belt, keeping forward momentum.
- C. Bringing the client to a nearby chair when she feels dizzy.
- D. Keeping the patient's body weight close to her own.
Correct Answer: B
Rationale: Pulling from the front of the gait belt (B) risks causing the client to lose balance or fall, requiring correction. Holding the belt (A), seating a dizzy client (C), and maintaining close body alignment (D) are appropriate and safe actions.
The nurse is recommending a change in the healthcare facility's policy and procedure regarding usage of restraint. To ensure that the nurse is providing findings from the highest quality of evidence, the nurse should include information from a
- A. detailed expert opinion.
- B. systematic review.
- C. quantitative study.
- D. qualitative study.
Correct Answer: B
Rationale: Systematic reviews (B) provide the highest quality evidence by synthesizing multiple studies, ideal for policy changes like restraint use. Expert opinions (A), quantitative (C), and qualitative studies (D) are lower in the evidence hierarchy.
The registered nurse (RN) is planning client care assignments. Which client would be appropriate to assign to the licensed practical/vocational nurse (LPN/VN)? A client
- A. with Guillain-Barre syndrome client reporting dyspnea while at rest.
- B. with stage 3 and 4 pressure injuries present in the sacral area.
- C. 2 hours postoperative total laryngectomy.
- D. awaiting a referral for outpatient diabetic support services.
Correct Answer: D
Rationale: A client awaiting a referral for diabetic support services (D) is stable and suitable for LPN care, involving coordination within scope. Guillain-Barré syndrome with dyspnea (A), severe pressure injuries (B), and recent laryngectomy (C) require RN assessment due to critical or complex needs.