- (Topic 7)
A client is admitted to the hospital with a diagnosis of aplastic anemia and placed on isolation. The nurse notices a family member entering the room without applying the appropriate apparel. The nurse will approach the family member using the following information as a basis for discussion:
Correct Answer:
C
(A) Although clients with a compromised immune system may acquire infections, the primary emphasis is on protecting the client. (B, D) Most people are aware of the guidelines once they see posted signs, so quoting regulations is not likely to result in consistent adherence to regulations. (C) Clients with aplastic anemia have white cell counts of 2000 or lower, making them more vulnerable to infections from others.
- (Topic 4)
A client has been admitted to the nursing unit with the diagnosis of severe anemia. She is slightly short of breath, has episodes of dizziness, and complains her heart sometimes feels like it will ??beat out of her chest.?? The physician has ordered her to receive 2 U of packed red blood cells. The most important nursing action to be taken is:
Correct Answer:
C
(A) An 18-gauge IV is an appropriate size for administering blood; however, client safety demands that the right blood product must be administered. (B) The consent form is legally necessary to be on the chart, but client safety is maintained by giving the correct blood component to the correct client. (C) Administering the correct blood product to the correct client will maintain physiological safety and minimize transfusion reactions. (D) The blood administration should take place over the ordered time frame designated by the physician.
- (Topic 7)
A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be:
Correct Answer:
B
(A) This outcome criterion is inadequate because the term ??accepts?? is not directly measurable. (B) This outcome criterion is directly measurable because specific goal-related verbalizations can be heard and verified by the nurse. (C) ??Improved perception of body image?? is not directly measurable and is therefore open to many interpretations. (D) Although long-term goals for the anorexic client should focus on increased self-esteem, this outcome criterion (as stated) does not include specific indicators or behaviors for which to observe.
- (Topic 5)
A client has renal failure. Today??s lab values indicate he has an elevated serum potassium. What additional priority information does the nurse need to obtain?
Correct Answer:
B
(A) The level of consciousness is not affected by elevated potassium levels. (B) An electrocardiogram (EKG) can tell the nurse whether this client is experiencing any cardiac dysfunction or arrhythmias related to the elevated potassium level. (C) Measurement of the urine output is not a priority nursing action at this time. (D) The client??s serum potassium values for the past several days may provide information about his renal function, but they are not a priority at this time.
- (Topic 4)
A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, ??The doctor said I have stones that need to be removed; where are they??? The nurse knows that the best explanation for this is to tell her that:
Correct Answer:
C
(A)Cholelithiasisis the correct term used to describe the presence of stones in the gallbladder. (B)Nephrolithiasis,orrenal calculi,is the correct term used to describe the presence of stones in the kidney. (C)Choledocholithiasisis the correct term used to describe the presence of stones in the common bile duct. (D)Cholecystitisis the correct term used to describe inflammation of the gallbladder and can be associated with cystic duct obstructions from impacted stones.