Nokea
The nurse is caring for the following clients. Which client should the nurse assess first?
- A. The client whose partial thromboplastin time (PTT) is 38 seconds.
- B. The client whose hemoglobin is 14 g/dL and hematocrit is 45%.
- C. The client whose platelet count is 75,000 per cubic millimeter of blood.
- D. The client whose red blood cell count is 4.8 x 106/mm3.
Correct Answer: C
Rationale: Platelets 75,000 (C) indicate thrombocytopenia, risking bleeding, a priority. PTT 38 (A) is therapeutic, Hb/Hct (B) are normal, and RBC 4.8 (D) is normal.
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The client diagnosed with leukemia has received a bone marrow transplant. The nurse monitors the client’s absolute neutrophil count (ANC). What is the client’s neutrophil count if the WBCs are 2.2 (x103/mm3), neutrophils are 25%, and bands are 5%?
Correct Answer: 660
Rationale: ANC = WBC × (neutrophils% + bands%). WBC = 2,200/mm3, neutrophils = 25%, bands = 5%. ANC = 2,200 × (0.25 + 0.05) = 2,200 × 0.3 = 660/mm3.
Cup of decatfeinated coffee for breakfast and lunch, 90 mL apple juice, 120 mL ice cream, 180 mL chicken broth, mashed potatoes, few bites of chicken, bowl of carrots, 240 mL milk, and 90 mL gelatin. How many milliliters should the nurse record for the client’s 8-hour fluid intake? __________ L (Record your answer as a whole number.)
Correct Answer: 2200
Rationale: First convert to milliliters: l L = 1000 mL;
1 oz = 30 mL
Next add the values for fluids: 1000 + 240 + 240 + 90 + 120 + 180 + 240 + 90 = 2200
Which of the following would be the most appropriate snack for a client who has iron deficiency anemia?
- A. Half of a grapefruit
- B. A carrot raisin salad
- C. A cup of yogurt
- D. Apple slices and cheese
Correct Answer: B
Rationale: Carrot raisin salad contains raisins, which are a good source of iron, making it appropriate for iron deficiency anemia.
Fifteen minutes after the nurse has initiated a transfusion of packed red blood cells, the client becomes restless and complains of itching on the trunk and arms. Which intervention should the nurse implement first?
- A. Collect urine for analysis.
- B. Notify the laboratory of the reaction.
- C. Administer diphenhydramine, an antihistamine.
- D. Stop the transfusion at the hub.
Correct Answer: D
Rationale: Restlessness/itching suggest a transfusion reaction; stopping at the hub (D) prevents further reaction. Urine collection (A), notification (B), and Benadryl (C) follow.
The client diagnosed with end-stage renal disease (ESRD) has developed anemia. Which would the nurse anticipate the HCP prescribing for this client?
- A. Place the client in reverse isolation.
- B. Discontinue treatments until blood count improves.
- C. Monitor CBC daily to assess for bleeding.
- D. Give client erythropoietin, a biologic response modifier.
Correct Answer: D
Rationale: ESRD causes erythropoietin deficiency; prescribing erythropoietin (D) treats anemia. Isolation (A), stopping treatment (B), and daily CBC (C) are inappropriate.