Nokea
The nurse is caring for a patient hospitalized with leukopenia. Which of the following assessments should be reported to the physician immediately?
- A. The blood pressure is 110/62.
- B. The apical pulse is 90.
- C. The temperature has increased from 98.6°F to 99.8°F.
- D. The respiratory rate is 24.
Correct Answer: C
Rationale: A temperature increase to 99.8°F in a patient with leukopenia (low white blood cell count) may indicate an infection which is a medical emergency due to the patient’s compromised immune system. The other vital signs are within normal limits and less urgent.
You may also like to solve these questions
The nurse is observing the ambulation of a client recently fitted for crutches. Which observation requires nursing intervention?
- A. Two finger widths are noted between the axilla and the top of the crutch.
- B. The client bears weight on his hands when ambulating.
- C. The crutches and the client's feet move alternately.
- D. The client bears weight on his axilla when standing.
Correct Answer: D
Rationale: Bearing weight on the axilla can cause nerve damage (e.g., brachial plexus injury); crutches should support weight on the hands.
The client is receiving a continuous heparin infusion. Which laboratory value should the nurse monitor most closely?
- A. Platelet count
- B. Prothrombin time (PT)
- C. Activated partial thromboplastin time (aPTT)
- D. International normalized ratio (INR)
Correct Answer: C
Rationale: Heparin’s anticoagulant effect is monitored by aPTT, with a therapeutic range of 1.5–2.5 times the control value. Platelet count is monitored for heparin-induced thrombocytopenia, but PT and INR are for warfarin.
The nurse is preparing to collect a sputum specimen from the client suspected of having tuberculosis. What is the correct method for obtaining a sputum specimen?
- A. Collect the specimen in the morning prior to breakfast.
- B. Collect the specimen on three consecutive days.
- C. Transport the collected specimen to the laboratory immediately.
- D. Offer mouth care after collecting the sputum specimen.
- E. Allow the client to rinse his mouth with an antiseptic solution prior to the sputum collection.
Correct Answer: A, B, C, D
Rationale: Morning collection (A) yieldsthough sputum is most concentrated. Three consecutive days (B) ensure reliable tuberculosis diagnosis. Immediate transport (C) prevents degradation. Mouth care (D) maintains hygiene. Antiseptic rinse (E) may kill bacteria, invalidating the sample.
The client is diagnosed with pancreatitis. Which laboratory value is most indicative of this condition?
- A. Elevated amylase
- B. Decreased bilirubin
- C. Elevated hemoglobin
- D. Decreased white blood cell count
Correct Answer: A
Rationale: Elevated amylase is a key indicator of pancreatitis, as it is released from damaged pancreatic tissue. Bilirubin, hemoglobin, and white blood cell counts are less specific, though leukocytosis may occur.
The nurse knows that children are more susceptible to respiratory tract infections owing to physiological differences. These childhood differences, adverts an adult, include:
- A. Fewer alveoli, slower respiratory rate
- B. Diaphragmatic breathing, larger volume of air
- C. Larger number of alveoli, diaphragmatic breathing
- D. Rounded shape of chest, smaller volume of air
Correct Answer: D
Rationale: Although a child has fewer alveoli than an adult, the child's respiratory rate is faster. Although a child may use diaphragmatic breathing, the adult exchanges a larger volume of air. The adult has a larger number of alveoli than a child. The child's chest is rounded whereas the adult chest is more of an oval shape, and the child does exchange a smaller volume of air than an adult.