Nokea
The nurse should ask all clients age 65 or older who are having surgery which question?
- A. Do you have Medicare Part A to help pay for the hospital reimbursement?'
- B. œDo you have an advance directive such as a health care proxy or living will?'
- C. œDo you have extra coverage to help pay for medications?'
- D. œDo you have Medicare Part B to help pay for your expenses?'
Correct Answer: B
Rationale: Asking about an advance directive ensures the client's wishes are documented, especially critical for older adults facing surgical risks, to guide care in case of incapacity.
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A client's bone marrow report reveals normal stem cells and precursors of platelets (megakaryocytes) in the presence of decreased circulating platelets. The nurse recognizes a knowledge deficit when the client makes which of the following statements?
- A. I need to stop flossing and throw away my hard toothbrush.'
- B. I am glad that my report turned out normal.'
- C. Now I know why I have all these bruises.'
- D. I shouldn't jump off that last step anymore.'
Correct Answer: B
Rationale: Normal stem cells and megakaryocytes with decreased circulating platelets suggest a peripheral destruction issue, such as ITP, not a bone marrow production problem. The client's statement that the report is 'normal' indicates a misunderstanding, as the low platelet count is abnormal and requires management. The other statements reflect appropriate awareness of bleeding risks.
Which factor besides the degree of neutropenia does the nurse assess in determining the client's risk of infection?
- A. Length of time neutropenia has existed.
- B. Health status before neutropenia.
- C. Body build and weight.
- D. Resistance to infection in childhood.
Correct Answer: A
Rationale: The duration of neutropenia significantly affects infection risk, as prolonged neutropenia increases exposure to pathogens. Pre-existing health status, body build, and childhood resistance are less directly relevant to current infection risk.
A client states that she is afraid of receiving vitamin B12 injections because of potential toxic effects, which is the nurse's best response to relieve these fears?
- A. Vitamin B12 will cause ringing in the ears before a toxic level is reached.'
- B. Vitamin B12 may cause a very mild rash initially.'
- C. Vitamin B12 may cause mild nausea but nothing toxic.'
- D. Vitamin B12 is generally free of toxicity because it is water-soluble.'
Correct Answer: D
Rationale: Vitamin B12 is a water-soluble vitamin, and excess amounts are excreted in urine, making toxicity rare. This response reassures the client by addressing her fear of toxic effects accurately. The other responses are incorrect, as B12 does not typically cause ringing in the ears, rash, or nausea as signs of toxicity.
The client with acute lymphocytic leukemia (ALL) is at risk for infection. What should the nurse do?
- A. Place the client in a private room.
- B. Have the client wear a mask.
- C. Have staff wear gowns and gloves.
- D. Restrict visitors.
Correct Answer: A
Rationale: Clients with ALL are immunocompromised due to neutropenia, increasing infection risk. Placing the client in a private room reduces exposure to pathogens. Masks, gowns, and visitor restrictions may be used in severe cases, but a private room is the first step.
The nurse should assess an older adult with macular degeneration for:
- A. Loss of central vision.
- B. Loss of peripheral vision.
- C. Total blindness.
- D. Blurring of vision.
Correct Answer: A
Rationale: Macular degeneration primarily affects the macula, leading to loss of central vision, which impairs activities like reading and recognizing faces.