Nokea
The nurse is developing a care plan for a client with leukemia. The plan should include which of the following? Select all that apply.
- A. Monitor temperature and report elevation.
- B. Recognize signs and symptoms of infection.
- C. Avoid crowds.
- D. Maintain integrity of skin and mucous membranes.
- E. Take a baby aspirin each day.
Correct Answer: A,B,C,D
Rationale: Leukemia increases infection risk due to impaired immune function. Monitoring temperature, recognizing infection signs, avoiding crowds, and maintaining skin/mucous membrane integrity are critical to prevent and detect infections. Baby aspirin is not indicated and may increase bleeding risk in leukemia.
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An older, sedentary adult may not respond to emotional or physical stress as well as a younger individual because of:
- A. Left ventricular atrophy.
- B. Irregular heartbeats.
- C. Peripheral vascular occlusion.
- D. Pacemaker placement.
Correct Answer: A
Rationale: Aging leads to left ventricular atrophy, reducing cardiac reserve and impairing the heart's ability to respond to stress, unlike irregular heartbeats or pacemakers.
A client with renal calculi has a history of dehydration. The nurse should:
- A. Encourage 3 L of fluid daily.
- B. Limit fluid to 1 L daily.
- C. Administer IV fluids only.
- D. Restrict activity.
Correct Answer: A
Rationale: High fluid intake (3 L) prevents stone formation by diluting urine.
The nurse is caring for a client who is receiving prescribed ketorolac. Which of the following client findings would indicate a therapeutic response? Select all that apply.
- A. Decreased pain
- B. Increased urinary output
- C. Decreased blood pressure
- D. Decreased temperature
- E. Increased muscle coordination
Correct Answer: A,D
Rationale: Ketorolac, an NSAID, reduces pain and inflammation, which can lower temperature in febrile clients. It does not directly affect urinary output, blood pressure, or muscle coordination.
Which of the following dietary measures would be useful in preventing esophageal reflux?
- A. Eating small, frequent meals.
- B. Increasing fluid intake.
- C. Avoiding air swallowing with meals.
- D. Adding a bedtime snack to the dietary plan.
Correct Answer: A
Rationale: Small, frequent meals reduce gastric distention and lower the risk of reflux compared to large meals. The other options are less effective or may worsen symptoms.
The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which of the following should be the nurse's first step in planning the dietary instructions?
- A. Determining the client's knowledge level about cholesterol.
- B. Asking the client to name foods that are high in fat, cholesterol, and salt.
- C. Explaining the importance of complying with the diet.
- D. Assessing the client's and family's typical food preferences.
Correct Answer: D
Rationale: Assessing food preferences ensures the dietary plan is tailored and practical.