Nokea
The nurse should assess a client with thrombocytopenia who has developed a hemorrhage for which of the following?
- A. Tachycardia.
- B. Bradycardia.
- C. Decreased urine output.
- D. Hypotension.
Correct Answer: A
Rationale: Hemorrhage in a client with thrombocytopenia can lead to hypovolemia, causing tachycardia as the heart compensates for decreased blood volume. Bradycardia is not typical, and while decreased urine output and hypotension may occur later, tachycardia is an earlier and more immediate sign.
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The nurse in the emergency department is administering an order for 20 mg intravenous furosemide (Lasix) which is to be given immediately. The nurse seems the client's identification and the medication barcode. The medication administration system does not verify that furosemide is ordered for this client; however, the furosemide is prepared in the accurate unit dose for intravenous infusion. The nurse should do which of the following next?
- A. Contact the pharmacist immediately to check the order and the barcode label for accuracy.
- B. Administer the medication now, knowing the medication is labeled and the client is identified.
- C. Report the problem to the information technology team to have the barcode system recalibrated.
- D. Ask another nurse to verify the medication and the client so the medication can be given now.
Correct Answer: A
Rationale: A barcode verification failure indicates a potential error, requiring immediate pharmacist consultation to confirm the order and ensure patient safety.
The nurse uses a Doppler ultrasound device to assess the client's lower extremities. In addition, the nurse calculates the ankle-brachial index to estimate stenosis of the:
- A. Arteries
- B. Aorta
- C. Carotid
- D. Veins
Correct Answer: A
Rationale: The ankle-brachial index (ABI) measures the ratio of ankle to brachial systolic blood pressure to assess arterial stenosis in the lower extremities. A low ABI indicates arterial narrowing, typical in PVD. It does not assess the aorta, carotid, or veins.
A client has had hoarseness for more than 2 weeks. The nurse should:
- A. Refer to a health care provider for a prescription for an antibiotic.
- B. Instruct the client to gargle with salt water at home.
- C. Assess the client for dysphagia.
- D. Instruct the client to take a throat analgesic.
Correct Answer: C
Rationale: Persistent hoarseness may indicate laryngeal pathology, including cancer; assessing for dysphagia (difficulty swallowing) helps evaluate severity and urgency. Antibiotics are inappropriate without a bacterial diagnosis. Gargling or analgesics may mask symptoms without addressing the cause.
What action should this nurse take to avoid spreading nosocomial infections?
- A. Remove the face mask.
- B. Remove the hair covering.
- C. Wash her hands before tying the strings on the mask.
- D. Tie the dangling strings of the mask around her neck.
Correct Answer: C
Rationale: Hand hygiene is critical to prevent nosocomial infections. Washing hands before handling the mask ensures the nurse does not contaminate it or transfer pathogens. Removing protective gear or tying strings improperly could increase infection risk.
Which nursing action is important in preventing cross-contamination?
- A. Change gloves immediately after use.
- B. Stand 2 feet from the client.
- C. Speak minimally when in the room.
- D. Wear long-sleeved shirts.
Correct Answer: A
Rationale: Changing gloves immediately after use prevents cross-contamination by removing potential pathogens from the nurse's hands before touching other surfaces or clients. The other actions are less effective in preventing contamination.