Nokea
The nurse is caring for a client with immune thrombocytopenic purpura. Which client statements indicate a need for further teaching? Select all that apply.
- A. I use a soft-bristle toothbrush and mild mouth rinse.
- B. I enjoy walking and wear nonskid footwear for safety.
- C. I use a safety razor and gentle shaving cream.
- D. I sometimes get constipated, so I have been taking docusate.
- E. I when I have a headache, I take over-the-counter ibuprofen.
Correct Answer: C,E
Rationale: ITP increases bleeding risk. Using a safety razor (C) risks cuts, and ibuprofen (E) inhibits platelets, both requiring further teaching. Soft toothbrush (A), safe walking (B), and docusate (D) are appropriate.
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The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse?
- A. Decreased breath sounds in right lower lobe
- B. Aspiration of a residual of 100 cc of formula
Correct Answer: A
Rationale: Decreased breath sounds in the right lower lobe may indicate aspiration or pneumonia, a serious complication requiring immediate intervention to ensure airway patency and prevent further respiratory compromise.
The nurse is caring for a client with cholelithiasis and acute cholecystitis. The client suddenly vomits 250 mL of greenish-yellow emesis and reports severe right upper quadrant pain with radiation to the right shoulder. Which intervention would have the highest priority?
- A. Administer promethazine suppository
- B. Initiate NPO status
- C. Insert nasogastric tube set to low suction
- D. Obtain prescription for pain medication
Correct Answer: B
Rationale: Acute cholecystitis with vomiting and severe pain suggests gallbladder inflammation or obstruction, requiring immediate cessation of oral intake (NPO status, B) to prevent further stimulation and complications like perforation. Promethazine (A) and pain medication (D) are supportive but secondary. A nasogastric tube (C) may be considered later but is not the priority.
A nurse is caring for a client 2 days after surgical creation of an arteriovenous fistula in the forearm. Which finding should the nurse report immediately to the health care provider?
- A. 2+ pitting edema of the extremity with the arteriovenous fistula
- B. Loud swooshing sound auscultated over the arteriovenous fistula
- C. Pale skin of the hand of the arm with the arteriovenous fistula
- D. Surgical site pain reported by the client as 3 on a scale of 0-10 during hand exercises
Correct Answer: C
Rationale: Pale skin in the hand (C) suggests vascular compromise, risking fistula failure or ischemia, requiring immediate reporting. Edema (A) is common, a swooshing sound (B) indicates patency, and mild pain (D) is expected.
Spinal headaches are a common occurrence following spinal anesthesia. Which of the following nursing interventions can help prevent a spinal headache?
- A. Placing the client in a quiet room.
- B. Significantly increasing the client's fluid intake.
- C. Administering PRN pain medication.
- D. Raising the head of the bed to $45^{\circ}$.
Correct Answer: B
Rationale: Increasing fluid intake helps maintain cerebrospinal fluid pressure, reducing the risk of spinal headaches post-spinal anesthesia.
A 6-year-old child is receiving chemotherapy for leukemia. Which comment by the child indicates to the nurse that the child is adjusting well to the therapy?
- A. I am so tired. I want Mommy to hold me.'
- B. Look at my new hat. I wear it all the time. It's pretty.'
- C. See all my bruises. They are funny colors.'
- D. I wish I could eat pizza, but everything makes me throw up.'
Correct Answer: B
Rationale: Wearing a hat proudly suggests positive coping with hair loss from chemotherapy, indicating adjustment, unlike complaints of fatigue, bruising, or nausea.