Nokea
The nurse working the organ transplant unit is caring for a client with a white blood cell count of 450. During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?
- A. Allow the client to keep the fruit
- B. Place the fruit next to the bed for easy access by the client
- C. Offer to wash the fruit for the client
- D. Ask the family members to take the fruit home
Correct Answer: D
Rationale: A white blood cell count of 450 indicates severe immunosuppression, so the fruit should be removed to prevent infection from potential contaminants.
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Four 6-month-old children arrive at the clinic for diphtheria-pertussis-tetanus immunization. Which child can safely receive the immunization at this time?
- A. the child with a runny nose
- B. the child who experienced a seizure after the last immunization
- C. the child who experienced a life-threatening allergic reaction after the last immunization
- D. the child with a temperature of 102°F
Correct Answer: A
Rationale: A mild runny nose is not a contraindication for the DTaP vaccine, whereas seizures, severe allergic reactions, or fever indicate a need to delay immunization.
A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy?
- A. Insulin requirements moderate as the pregnancy progresses.
- B. A decreased need for insulin occurs during the second trimester.
- C. Elevations in human chorionic gonadotrophin decrease the need for insulin.
- D. Fetal development depends on adequate insulin regulation.
Correct Answer: D
Rationale: Adequate insulin regulation is critical for fetal development in diabetic pregnancies.
The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because:
- A. Grimacing and writhing movements decrease with relaxation and rest.
- B. Hypoactive deep tendon reflexes become more active with rest.
- C. Stretch reflexes are increased with rest.
- D. Fine motor movements are improved by rest.
Correct Answer: A
Rationale: Rest reduces spasticity and involuntary movements in cerebral palsy.
What would the nurse expect the admitting assessment to reveal in a client with glomerulonephritis?
- A. Hypertension
- B. Lassitude
- C. Fatigue
- D. Vomiting and diarrhea
Correct Answer: A
Rationale: Glomerulonephritis often causes hypertension due to fluid retention and renal dysfunction.
The patient is prescribed metronidazole (Flagyl) for adjunct treatment for a duodenal ulcer. When teaching about this medication, the nurse would include:
- A. This medication should be taken only until you begin to feel better.'
- B. This medication should be taken on an empty stomach to increase absorption.'
- C. While taking this medication, you do not have to be concerned about being in the sun.'
- D. While taking this medication, alcoholic beverages and products containing alcohol should be avoided.'
Correct Answer: D
Rationale: Metronidazole can cause a disulfiram-like reaction with alcohol, so avoidance is critical.