Nokea
Which of the following responses would be most appropriate for the nurse when comforting a primiparous client whose critically ill neonate delivered at 25 weeks dies while the mother is present?
- A. This is probably for the best because his organs were so immature.'
- B. You should try to get pregnant again soon to get over this loss.'
- C. You can stay with your baby as long as you want and say anything you want.'
- D. If you want me to, I can call the chaplain to stay with you.'
Correct Answer: C
Rationale: Allowing the mother to stay with her baby and express herself supports grieving and closure, which is most appropriate in this situation.
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A client is receiving heparin therapy for a pulmonary embolism. The nurse should monitor the client for which of the following adverse effects?
- A. Thrombocytopenia.
- B. Hyperkalemia.
- C. Hypoglycemia.
- D. Hypertension.
Correct Answer: A
Rationale: Heparin can cause heparin-induced thrombocytopenia, a serious adverse effect that reduces platelet count and increases clotting risk, requiring close monitoring.
A client with metastatic cancer of the liver is concerned about his progress. Which of the following nursing interventions is most appropriate?
- A. Provide information for the client to consider a liver transplantation.
- B. Assure the client that the prescribed medications will shrink all tumor sites.
- C. Explain the effects of chemotherapy.
- D. Place emphasis on providing symptomatic and comfort measures.
Correct Answer: D
Rationale: For metastatic liver cancer, palliative care focusing on symptom relief and comfort is most appropriate, as transplantation or tumor shrinkage may not be feasible.
When giving a client a tube feeding the nurse should:
- A. Warm the feeding solution before administration.
- B. Place the client in a left side-lying position.
- C. Aspirate residual gastric contents before the feeding and discard.
- D. Verify position of the tube before beginning feeding.
Correct Answer: D
Rationale: Verifying tube position (e.g., via pH testing or X-ray) is critical to ensure safe administration and prevent aspiration.
A client diagnosed with refractory myasthenia gravis is told by the primary health care provider that plasmapheresis therapy is indicated. When the client asks the nurse to repeat the primary health care provider's reason for prescribing this treatment, the nurse should tell the client that this therapy will most likely improve which problem?
- A. Double vision
- B. Difficulty breathing
- C. Urinary incontinence
- D. Prickling sensation in the legs
Correct Answer: B
Rationale: Plasmapheresis is a process that separates the plasma from the blood elements so that plasma proteins that contain antibodies can be removed. It is used as an adjunct therapy in myasthenia gravis and may give temporary relief to clients with actual or impending respiratory failure. Usually 3 to 5 treatments are required. This therapy is not indicated for the reasons listed in any of the other options.
The nurse is evaluating a diabetic client's understanding of the signs of hyperglycemia. Which statement by the client reflects an understanding?
- A. I may become diaphoretic and faint.
- B. I may notice signs of fatigue, dry skin, and increased urination.
- C. I need to take an extra diabetic pill if my blood glucose is greater than 300.
- D. I should restrict my fluid intake if my blood glucose is greater than 250.
Correct Answer: B
Rationale: Fatigue, dry skin, polyuria, and polydipsia are classic symptoms of hyperglycemia. Fatigue occurs because of lack of energy from the inability of the body to use glucose. Dry skin occurs secondary to dehydration related to polyuria. Polydipsia occurs secondary to fluid loss. Diaphoresis is associated with hypoglycemia. A client should not take extra hypoglycemic agents to reduce an elevated blood glucose level. A client with hyperglycemia becomes dehydrated secondary to the osmotic effect of the elevated glucose; therefore, the client must increase fluid intake.