Nokea
The nurse talking with a client with polycythemia vera. Which of the following statements by the client would require follow-up?
- A. I will drink plenty of water every day
- B. I should take a low-dose aspirin every day
- C. I need to have blood removed periodically
- D. I will continue taking my daily multivitamin with iron
Correct Answer: D
Rationale: Iron supplements can worsen polycythemia vera by increasing red blood cell production. Hydration, aspirin, and phlebotomy are appropriate management strategies.
You may also like to solve these questions
Following a motor vehicle accident, the client does not know where he is or what year it is and has short-term memory impairment. Which nursing action is most appropriate?
- A. Offer several choices to the client.
- B. Give simple directions to the client.
- C. Give the client the details of the care.
- D. Offer written instructions to the client.
Correct Answer: B
Rationale: Simple directions accommodate memory impairment and disorientation, enhancing comprehension and safety post-accident.
A client asks, 'What should I do to prepare for a colonoscopy?' Which instructions should the nurse reinforce to correctly answer the client’s question? Select all that apply.
- A. No food or drink is allowed 8 hours prior to the test
- B. Prophylactic antibiotics are taken as prescribed
- C. Smoking must be avoided after midnight
- D. The day prior to the procedure your diet will be clear liquids
- E. You will drink polyethylene glycol as directed the day before
Correct Answer: A,D,E
Rationale: Fasting 8 hours, clear liquids the day before, and polyethylene glycol are standard colonoscopy preparations. Antibiotics are not routine, and smoking cessation is not specific to the procedure.
The client has an IV in place when he returns for surgery. While examining the IV site, the licensed practical nurse notices pallor, coolness, and edema. The nurse is aware that these are signs of:
- A. Infiltration
- B. Infection
- C. Thrombus formation
- D. Sclerosing of the vein
Correct Answer: A
Rationale: Pallor, coolness, and edema at an IV site indicate infiltration, where IV fluid leaks into surrounding tissue. Infection shows redness and warmth, thrombus formation may cause pain and redness, and sclerosing involves vein hardening, not edema.
A client is admitted for treatment of hypoparathyroidism. Based on the client's diagnosis, the nurse would anticipate an order for:
- A. Potassium
- B. Magnesium
- C. Calcium
- D. Iron
Correct Answer: C
Rationale: The parathyroid is responsible for calcium and phosphorus absorption. Clients with hypoparathyroidism have hypocalcemia. Answers A, B, and D are not associated with hypoparathyroidism; therefore, they are incorrect.
While caring for a client in skeletal traction, which tasks can the nurse assign to experienced unlicensed assistive personnel to help prevent immobility hazards? Select all that apply.
- A. Assist with active and passive range of motion exercises
- B. Change bed linens while logrolling the client from side to side
- C. Check the color and temperature of the affected extremity
- D. Reapply pneumatic compression device after bathing the client
- E. Remind the client to use the incentive spirometer
Correct Answer: A,D,E
Rationale: Assisting with range of motion, reapplying compression devices, and reminding about spirometry are within UAP scope and prevent immobility issues. Assessing extremities and logrolling require nursing judgment.