Nokea
The nurse should instruct the client with a platelet count of less than 150,000/µL to avoid which of the following activities?
- A. Ambulation.
- B. Valsalva's maneuver.
- C. Visiting with children.
- D. Semi-Fowler's position.
Correct Answer: B
Rationale: A platelet count below 150,000/µL indicates thrombocytopenia, increasing bleeding risk. Valsalva's maneuver (e.g., straining during bowel movements) can raise intracranial pressure and cause bleeding, such as cerebral hemorrhage, and should be avoided. Ambulation, visiting children, and semi-Fowler's position are generally safe unless other conditions are present.
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Which clinical manifestations should the nurse expect to assess in a client diagnosed with an overdose of a cholinergic agent?
- A. Dry mucous membranes.
- B. Urinary incontinence.
- C. Central nervous system (CNS) depression.
- D. Seizures.
- E. Skin rash.
Correct Answer: B,C,D
Rationale: Cholinergic overdose (e.g., organophosphates) causes urinary incontinence (B), CNS depression (C), and seizures (D) due to excessive acetylcholine. Dry mucous membranes and skin rash are not typical.
Which of the following interventions would be the most appropriate for preventing the development of a paralytic ileus in a client who has undergone renal surgery?
- A. Encourage the client to ambulate every 2 to 4 hours.
- B. Offer 3 to 4 oz of a carbonated beverage periodically.
- C. Encourage use of a stool softener.
- D. Continue I.V. fluid therapy.
Correct Answer: A
Rationale: Ambulation stimulates bowel motility, reducing the risk of paralytic ileus post-renal surgery by promoting gastrointestinal function.
The nurse has an order to administer 2 oz of lactulose (Cephulac) to a client who has cirrhosis. How many milliliters of lactulose should the nurse administer?
Correct Answer: 60 mL
Rationale: 2 oz = 60 mL (1 oz = 30 mL). Thus, the nurse should administer 60 mL of lactulose.
A client has mitral stenosis and is a prospective valve recipient. The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which of the following regimens would pose the greatest health hazard to this client at this time?
- A. Medication therapy.
- B. Diet modification.
- C. Activity restrictions.
- D. Dental care.
Correct Answer: A
Rationale: Medication therapy (e.g., anticoagulants, diuretics) is critical to manage symptoms and prevent complications like thromboembolism in mitral stenosis.
Which dietary restriction is critical in acute renal failure?
- A. Low sodium.
- B. High protein.
- C. Low carbohydrate.
- D. High potassium.
Correct Answer: A
Rationale: Low sodium prevents fluid retention and hypertension in acute renal failure.