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When a client is diagnosed with aplastic anemia, the nurse should assess the client for changes in which of the following physiologic functions?
- A. Bleeding tendencies.
- B. Intake and output.
- C. Peripheral sensation.
- D. Bowel function.
Correct Answer: A
Rationale: Aplastic anemia causes pancytopenia, including thrombocytopenia, which increases the risk of bleeding. The nurse should assess for bleeding tendencies, such as petechiae, bruising, or mucosal bleeding. Intake/output, sensation, and bowel function are not primarily affected.
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In providing care to the client with leukemia who has developed thrombocytopenia, the nurse assesses the most common sites for bleeding. Which of the following is not a common site?
- A. Biliary system.
- B. Gastrointestinal tract.
- C. Brain and meninges.
- D. Pulmonary system.
Correct Answer: A
Rationale: Thrombocytopenia in leukemia increases bleeding risk in the gastrointestinal tract, brain/meninges, and pulmonary system due to mucosal surfaces and vascularity. The biliary system is not a common site for bleeding.
The client has a nursing diagnosis of Self-care deficit related to the confinement of traction. Which of the following would indicate a successful outcome for this diagnosis?
- A. The client assists as much as possible in his care, demonstrating increased participation over time.
- B. The client allows the nurse to complete his care in an efficient manner without interfering.
- C. The client allows his wife to assume total responsibility for his care.
- D. The client allows his wife to complete his care to promote feelings of usefulness.
Correct Answer: A
Rationale: Increased participation in self-care indicates progress toward independence despite traction limitations.
A 42-year-old female is interested in making dietary changes to reduce her risk of colon cancer. What dietary selections should the nurse suggest?
- A. Croissant, granola and peanut butter squares, whole milk.
- B. Bran muffin, skim milk, stir-fried broccoli.
- C. Granola, bagel with cream cheese, cauliflower salad.
- D. Oatmeal, raisin cookies, baked potato with sour cream, turkey sandwich.
Correct Answer: B
Rationale: A diet high in fiber (bran muffin, broccoli) and low in fat (skim milk) reduces colon cancer risk by promoting healthy digestion and reducing carcinogenic exposure in the colon.
A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which of the following indicates this client is ready to be discharged?
- A. The client voids 500 mL of urine.
- B. The client tolerates eating a hamburger.
- C. The client is pain-free.
- D. The client walks in the hallway unassisted.
Correct Answer: A
Rationale: Voiding 500 mL indicates normal bladder function, a key discharge criterion after hernia repair, ensuring no urinary retention from anesthesia or surgery.
A postoperative client is prescribed enoxaparin (Lovenox) 40 mg subcutaneous daily. Which laboratory value should the nurse monitor?
- A. Platelet count.
- B. Prothrombin time (PT).
- C. Activated partial thromboplastin time (aPTT).
- D. International normalized ratio (INR).
Correct Answer: A
Rationale: Enoxaparin can cause thrombocytopenia. Monitoring platelet count ensures early detection of this potential adverse effect.