Nokea
A 57-year-old man admitted with metastatic cancer has been receiving chemotherapy for 3 months. His lab values include: RBC 3.8 million/mm³, WBC 3,000/mm³, Hgb 9.3 g/dL, platelets 50,000/mm³.
The nurse would expect the patient to exhibit which of the following symptoms?
- A. BP 120/70, pulse 100, respirations 16.
- B. Ankle edema and ascites.
- C. Flushed face and light stools.
- D. Nausea, anorexia, and vomiting.
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the situation. (1) correct-increased pulse and respirations are caused by decreased oxygenation of tissues (2) no information to suggest this is provided in the question (3) will be pale due to anemia, normal RBC male 4.3-5.9 million/mm³, female 3.5-5.5 million/mm³, decreased with anemia; normal WBC 4,500-11,000/mm³, decreased (leukopenia) causes susceptibility to infection; normal Hgb - male 13.5-17.5 g/dL, female 12-16 g/dL, decreased with anemia (4) not related to information provided in the question
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An 11-month-old baby is having trouble gaining weight after discharge from the hospital. Which of the following actions by the nurse is BEST?
- A. Observe the child at mealtime.
- B. Inquire about the child's eating patterns.
- C. Weigh the baby each month.
- D. Attempt to feed the baby for the mother.
Correct Answer: A
Rationale: Observing mealtime assesses feeding behaviors and parental interactions, identifying causes of poor weight gain. Options B, C, and D are less direct or premature.
A 22-year-old woman comes to the hospital at term in the early stages of labor. A diagnosis of complete placenta previa is made.
It would be MOST important for the nurse to take which of the following actions?
- A. Start an IV of terbutaline (Brethine) and monitor the patient's vital signs closely.
- B. Prepare the patient for an immediate cesarean section.
- C. Maintain the patient on bedrest until spontaneous vaginal delivery is achieved.
- D. Monitor the patient's length and duration of contractions.
Correct Answer: B
Rationale: Strategy: Answers are both assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. Is it desired? (1) implementation, Brethine used to delay delivery in preterm labor (2) correct-implementation, cannot deliver vaginally (3) implementation, cannot deliver vaginally (4) assessment, cannot deliver vaginally, cesarean section must be performed
The nurse is teaching a client with a new diagnosis of migraine headaches about sumatriptan (Imitrex). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication at the first sign of a headache.
- B. I should avoid driving after taking this medication.
- C. I should report chest pain to my doctor.
- D. I should take this medication every morning to prevent headaches.
Correct Answer: D
Rationale: Taking sumatriptan daily to prevent migraines is incorrect, as it is used to abort acute attacks, not for prophylaxis. Options A, B, and C are correct: early use maximizes efficacy, sedation may impair driving, and chest pain may indicate vasoconstriction.
An 87-year-old woman is admitted to the acute care hospital for heart failure. The nurse asks about the client's signs and symptoms and obtains vital signs. Considering the client's age, what additional question is most important for the nurse to ask?
- A. How do you manage your bowels?
- B. When was your last menstrual period?
- C. What are your favorite foods?
- D. When was your last tetanus shot?
Correct Answer: D
Rationale: Elderly patients are at risk for tetanus due to waning immunity; assessing vaccination status is critical for infection prevention.
The doctor has ordered nasogastric feedings for an elderly client with dysphagia. Prior to administering a tube feeding, the nurse should:
- A. Discard any aspirant and begin the tube feeding.
- B. Check the pH of the aspirant.
- C. Connect the tubing to suction.
- D. Mix the feeding with 200 mL of water.
Correct Answer: B
Rationale: Checking the pH of gastric aspirant confirms tube placement in the stomach (pH <5). Discarding aspirant risks fluid loss, suction is not routine, and mixing with water dilutes the feeding.