Nokea
The nurse should teach the neutropenic client and the family to avoid which of the following?
- A. Using suppositories or enemas.
- B. Using a high-efficiency particulate air (HEPA) filter mask.
- C. Performing perianal care after every bowel movement.
- D. Performing oral care after every meal.
Correct Answer: A
Rationale: Neutropenic clients should avoid suppositories or enemas, as they can cause rectal trauma and introduce infections. HEPA masks, perianal care, and oral care are recommended to reduce infection risk.
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When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:
- A. Decreased blood volume
- B. Increase in muscular activity
- C. Increased venous pressure
- D. Increased arterial pressure
Correct Answer: C
Rationale: Bilateral ankle edema in PVD is often due to increased venous pressure from venous insufficiency or right-sided heart failure, which impairs venous return and causes fluid to pool in the lower extremities. Decreased blood volume or increased muscular activity does not cause edema, and arterial pressure is not directly related.
When teaching the diabetic client about foot care, the nurse should instruct the client to do which of the following?
- A. Avoid going barefoot.
- B. Buy shoes a half size larger.
- C. Cut toenails at angles.
- D. Use heating pads for sore feet.
Correct Answer: A
Rationale: Diabetic clients should avoid going barefoot to prevent foot injuries, which can lead to serious complications due to poor healing and neuropathy.
A client with advanced Hodgkin's disease is admitted to hospice because death is imminent. The goal to address for the client is:
- A. Fear of pain.
- B. Fear of further therapy.
- C. Feelings of isolation.
- D. Feelings of social inadequacy.
Correct Answer: A
Rationale: In hospice care for advanced Hodgkin's disease, the primary goal is to address fear of pain, ensuring comfort as death approaches. Fear of therapy, isolation, and social inadequacy are less relevant at this stage.
The nurse receives the preoperative blood work report for a client who is scheduled to undergo surgery. Which of the following laboratory findings should be reported to the surgeon?
- A. Red blood cells, 4.5 million/mm³.
- B. Creatinine, 2.6 mg/dL.
- C. Hemoglobin, 12.2 g/dL.
- D. Blood urea nitrogen, 15 mg/dL.
Correct Answer: B
Rationale: A creatinine level of 2.6 mg/dL indicates renal impairment, which can affect anesthesia and surgical outcomes. This must be reported to the surgeon. The other values are within normal ranges.
Which of the following interventions should the nurse anticipate incorporating into the client's plan of care when hepatic encephalopathy initially develops?
- A. Inserting a nasogastric (NG) tube.
- B. Restricting fluids to 1,000 mL/day.
- C. Administering I.V. salt-poor albumin.
- D. Implementing a low-protein diet.
Correct Answer: D
Rationale: A low-protein diet (D) reduces ammonia production in hepatic encephalopathy. NG tubes (A), fluid restriction (B), and albumin (C) are not primary interventions.