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The nurse notes that the daily white blood cell (WBC) count in a client with aplastic anemia has dropped overnight from 3,900 to 2,900/µL. Which is the appropriate nursing intervention?
- A. Continue monitoring the client.
- B. Call the laboratory to verify the report.
- C. Document the finding.
- D. Call the physician and place the client in reverse isolation.
Correct Answer: D
Rationale: A significant drop in WBC count (3,900 to 2,900/µL) in aplastic anemia indicates worsening neutropenia, increasing infection risk. The nurse should notify the physician and place the client in reverse isolation to protect against infections. Monitoring, verifying, or documenting alone are insufficient given the urgency.
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A 42-year-old husband and father of a 7-year-old girl and a 10-year-old boy is concerned about what he should tell his children regarding his wife's impending death from aggressive breast cancer. The nurse should:
- A. Refer the family to pastoral care services.
- B. Encourage the husband to come to terms with his own grief first.
- C. Suggest that the children be told nothing until after death occurs.
- D. Begin education about strategies for communication with his children.
Correct Answer: D
Rationale: Educating the husband on communication strategies helps him prepare his children for their mother's death, fostering understanding and emotional support.
A suspected outbreak of anthrax has been transmitted by skin exposure. A client is admitted to the emergency department with lesions on the hands. The physician prescribes antibiotics and sends the client home. What should the nurse instruct the client to do? Select all that apply.
- A. Take the prescribed antibiotics for 60 days.
- B. Avoid contact with other members of the family during the treatment period.
- C. Wear a mask for 60 days.
- D. Expect the skin lesions to clear up within 1 to 2 weeks.
- E. Wash hands frequently.
Correct Answer: A,D,E
Rationale: Cutaneous anthrax requires antibiotics for 60 days, frequent hand washing to prevent spread, and lesions typically resolve in 1-2 weeks with treatment. Masks and family isolation are unnecessary for cutaneous anthrax.
Which of the following are expected outcomes for a client with pulmonary disease?
- A. A relatively matched ventilation-to-perfusion ratio.
- B. A low ventilation-to-perfusion ratio.
- C. A high ventilation-to-perfusion ratio.
- D. An equal PaO2 and PaCO2 ratio.
Correct Answer: A
Rationale: A matched ventilation-to-perfusion ratio is the goal in pulmonary disease for efficient gas exchange. Low or high ratios indicate mismatch. Equal PaO2 and PaCO2 is not a standard outcome.
The home health nurse is discussing the administration of insulin glargine with a client. It would require follow-up if the client states that insulin glargine must be administered
- A. only in the abdomen.
- B. using a 6 mm and 31-gauge insulin syringe.
- C. only with a meal.
- D. after rolling the vial of insulin.
- E. within 28 days of opening the vial.
Correct Answer: A,C,D
Rationale: Insulin glargine can be administered in multiple sites, not only the abdomen; it is given regardless of meals; and it should not be rolled, as it is a clear solution.
Which intervention is appropriate for a client on hemodialysis?
- A. Check fistula for a thrill.
- B. Restrict all fluids.
- C. Administer heparin post-dialysis.
- D. Encourage high-protein diet.
Correct Answer: A
Rationale: Checking for a thrill ensures fistula patency for dialysis.