Nokea
The nurse provides education to a patient with thrombocytopenia about precautions to be taken at home. The nurse identifies that further teaching is needed when the patient performs which action?
- A. Drinks 14 glasses of water daily.
- B. Shaves once a day using an electric razor.
- C. Uses an alcohol-based mouthwash twice a day.
- D. Brushes teeth with a soft-bristle toothbrush twice a day.
Correct Answer: C
Rationale: Using alcohol-based mouthwash can irritate oral mucosa and cause bleeding in thrombocytopenia, indicating a need for further teaching.
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A patient's blood pressure (BP) reading is 142/91 mm Hg. How would the nurse classify the BP?
- A. Normal.
- B. Prehypertension.
- C. Hypertension, stage 1.
- D. Hypertension, stage 2.
Correct Answer: C
Rationale: A BP of 142/91 mm Hg is classified as stage 1 hypertension, with systolic 140-159 mm Hg or diastolic 90-99 mm Hg.
A patient reports episodic chest pain lasting a few minutes that is provoked by exertion and relieved within 10 minutes upon resting. Which cause of the patient's symptoms would the nurse suspect?
- A. Spasm of a major coronary artery.
- B. Exposure of the thrombogenic surface to plaque.
- C. Myocardial ischemia due to coronary artery disease.
- D. Myocardial ischemia secondary to microvascular disease.
Correct Answer: C
Rationale: Myocardial ischemia due to coronary artery disease causes chest pain provoked by exertion and relieved by rest, characteristic of stable angina.
Which finding would the nurse expect to see in a patient with a hemoglobin level of 8 g/dL? Select all that apply.
- A. Palpitations.
- B. Conjunctival pallor.
- C. Sternal tenderness.
- D. Heart rate of 104 beats/min.
Correct Answer: B,D
Rationale: Conjunctival pallor and tachycardia (heart rate of 104 beats/min) are common in anemia, reflecting reduced hemoglobin and compensatory mechanisms.
Which role is attributed to the base in the acid-base balance?
- A. Does not interact with acids.
- B. Promotes the excretion of acid.
- C. Activates the system of acid-base balance.
- D. Increases the action of the hydrogen ions.
Correct Answer: B
Rationale: Bases, like bicarbonate, promote acid excretion by neutralizing hydrogen ions, aiding in maintaining acid-base balance.
Which information will the nurse include when teaching a patient who is receiving chemotherapy for leukemia?
- A. The treatment has severe side effects, some of which will be permanent.
- B. You need to use your call light to ask for help every time you get out of bed.
- C. Prevention and early detection of infection are important during leukemia treatment.
- D. Feeling isolated is a common and unavoidable consequence of leukemia treatment.
Correct Answer: C
Rationale: Prevention and early detection of infection are critical during leukemia chemotherapy due to immune suppression, a key patient education point.