Nokea
The parents of a 15 month-old child asks the nurse to explain their child's lab results and how they show the child has iron deficiency anemia. The nurse's best response is
- A. Although the results are here, your doctor will explain them later.
- B. Your child has fewer red blood cells that carry oxygen.
- C. The blood cells that carry nutrients to the cells are too large.
- D. There are not enough blood cells in your child's circulation.
Correct Answer: B
Rationale: Your child has fewer red blood cells that carry oxygen. This provides a simple explanation of iron deficiency anemia.
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The practical nurse is assisting with care for several newborns in the nursery. Which of the following findings are abnormal and need to be reported to the registered nurse? Select all that apply.
- A. Chest wall retractions
- B. Flaking skin on the feet
- C. Head circumference of 13½ inches (34 cm)
- D. Jaundice of the head and sclera
- E. No documentation of voiding in past 24 hours
Correct Answer: A, D, E
Rationale: Chest retractions (A), jaundice (D), and no voiding (E) are abnormal and require reporting. Flaking skin (B) and head circumference (C) are normal for newborns.
A client with a panic disorder has a new prescription for Xanax (alprazolam). In teaching the client about the drug's actions and side effects, which of the following should the nurse emphasize?
- A. Short-term relief can be expected
- B. The medication acts as a stimulant
- C. Dosage will be increased as tolerated
Correct Answer: A
Rationale: Short-term relief can be expected. Xanax is a short-acting benzodiazepine useful in controlling panic symptoms quickly.
The nurse is caring for a client who has bacterial meningitis. Which of the following actions should the nurse take? Select all that apply.
- A. Minimize environmental stimuli.
- B. Implement seizure precautions.
- C. Maintain the head of bed at 30 degrees.
- D. Keep a surgical mask on the client at all times.
- E. Place the client in a room with monitored negative air pressure.
Correct Answer: A, B, C
Rationale: Minimizing stimuli (A), seizure precautions (B), and elevating the head (C) reduce complications in meningitis. Masks (D) are unnecessary, and negative pressure rooms (E) are for airborne diseases.
The nurse is caring for a client with leukemia who is receiving the drug doxorubicin (Adriamycin). Which, if occurred, would be reported to the charge nurse immediately due to the toxic effects of this drug?
- A. Rales and distended neck veins
- B. Red discoloration of the urine and an output of 75 ml the previous hour
- C. Nausea and vomiting
- D. Elevated BUN and dry flaky skin
Correct Answer: A
Rationale: This drug can cause cardiotoxicity exhibited by changes in the ECG and congestive heart failure. Rales and distended neck veins are clinical manifestations of congestive heart failure, so answer A is correct. A reddish discoloration to the urine is a harmless side effect, so answer B is incorrect. An elevated BUN and dry, flaky skin are not specific to this drug, so answers C and D are incorrect.
The nurse is caring for a client receiving chemotherapy. The client is prescribed filgrastim to improve the function of the immune system. Which finding does the nurse anticipate in response to the medication?
- A. Decrease in serum uric acid
- B. Increase in hemoglobin level
- C. Increase in neutrophil count
- D. Increase in platelet count
Correct Answer: C
Rationale: Filgrastim stimulates neutrophil production, so an increase in neutrophil count (C) is expected. It does not affect uric acid (A), hemoglobin (B), or platelets (D).