Nursing 308 Questions With Complete Solutions
A 25-year-old male is admitted in sickle cell crisis. Which of the
following interventions would be of highest priority for this
client?
A) Taking hourly blood pressures with mechanical cuff
B) Encouraging fluid intake of at least 200mL per hour
C) Position in high Fowler's with knee gatch raised
D) Administering Tylenol as ordered Correct Answer
Answer:
B: Encouraging fluid intake of at least 200ml per hour
Rationale:
It is important to keep the client in sickle cell crisis hydrated to
prevent further sickling of the blood. Dehydration is a common
cause of sickling. Answer A is incorrect because a mechanical
cuff places too much pressure on the arm. Answer C is incorrect
because raising the knee gatch impedes circulation. Answer D is
incorrect because Tylenol is too mild an analgesic for the client
in crisis.
A 60-year-old comes into the emergency department with
crushing substernal chest pain that radiates to the shoulder and
left arm. The admitting diagnosis is acute myocardial infarction
(MI). Admission prescriptions include oxygen by nasal cannula
at 4 L/min, complete blood count (CBC), a chest radiograph, a
12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate
given IV. The nurse should first:
A. Administer the morphine
B. Obtain a 12-lead ECG
C. Obtain the blood work
,D. Prescribe the chest radiograph Correct Answer A.
Administer the morphine
Rationale: Although obtaining the ECG, chest radiograph, and
blood work are all important, the nurse's priority action should
be to relieve the crushing chest pain. Therefore, administering
morphine sulfate is the priority action.
A 68-year-old woman is diagnosed with thrombocytopenia due
to acute lymphocytic leukemia. She is admitted to the hospital
for treatment. The nurse should assign the patient:
A. to a private room so she will not infect other patients and
health care workers.
B. to a private room so she will not be infected by other patients
and health care workers.
C. to a semiprivate room so she will have stimulation during her
hospitalization.
D. to a semiprivate room so she will have the opportunity to
express her feelings about her illness. Correct Answer
Answer: B
What are the needs of the patient with acute lymphocytic
leukemia and thrombocytopenia?
Needed Info: Lymphocytic leukemia, disease characterized by
proliferation of immature WBCs. Immature cells unable to fight
infection as competently as mature white cells. Treatment:
chemotherapy, antibiotics, blood transfusions, bone marrow
transplantation. Nursing responsibilities: private room, no raw
fruits or vegs, small frequent meals, O2, good skin care.
,B. to a private room so she will not be infected by other patients
and health care workers - CORRECT: protects patient from
exogenous bacteria, risk for developing infection from others
due to depressed WBC count, alters ability to fight infection
A client comes into the emergency room with complaints of
sudden onset of severe right flank pain. While tests are being
performed, it is MOST important for the nurse to take which of
the following actions?
a) Make sure the the patient does not eat or drink anything
b) Strain all the patient's urine through several layers of gauze
c) Check the patient's grip strength and pupil reactivity
d) Send blood and urine specimens to the lab for analysis
Correct Answer B) Strain all the patient's urine through several
layers of gauze
Rationale: "b" is the correct answer. "MOST" indicates a
priority question. Symptoms suggest urinary caculi and should
strain urine for stone. Needed information: Symptoms of renal
calculi include- pain, diaphoresis, nausea and vomiting, fever
and chills, hematuria. Nursing care: monitor I&O and temp,
suggest increase in fluids, strain urine and check pH of urine,
and administer analgesics. Diet for prevention of stones:
consume foods low in calcium, sodium, and oxalates, avoid
vitamin D enriched foods, decrease purine sources, restrict citrus
fruits, milk, and potatoes.
A client had a right total hip arthroplasty 2 days ago. Which
precautions will the nurse teach the client to prevent surgical
complications? Select all that apply.
A. "Stand on your right leg to pivot to the chair"
, B. "Do not bend your leg more than 90 degrees"
C. "Cross your legs to be more comfortable"
D. "Avoid twisting your body when moving"
E. "Use a long-handled shoe horn to put on your shoes" Correct
Answer Correct Answers: B, D, and E
Rationale:
B, D, and E are proper ways to care for clients with THA. A and
C can lead to dislocation of the affected hip. Chart 18-3 on page
298 contains information on precautions, pain management, and
care for patients with THA
A client had surgery two (2) days ago and reports having a
moderate amount of pain, stating that it is "a 7 on a 1 to 10
scale" of intensity. What intervention has the highest priority in
the client's nursing care plan?
A. Encouraging diversional activities
B. Incorporating ADLs as soon as possible
C. Teaching key points of the relaxation response
D. Using preemptive analgesia Correct Answer Answer: D:
Using preemptive analgesia
Rationale:
Use of preemptive analgesia is a technique designed to decrease
pain in the postoperative period, decrease the requirements for a
postoperative analgesic, prevent morbidity, and decrease the
hospital stay.
A client has taken steroids for 12 years to help manage chronic
obstructive pulmonary disease (COPD). When making a home
A 25-year-old male is admitted in sickle cell crisis. Which of the
following interventions would be of highest priority for this
client?
A) Taking hourly blood pressures with mechanical cuff
B) Encouraging fluid intake of at least 200mL per hour
C) Position in high Fowler's with knee gatch raised
D) Administering Tylenol as ordered Correct Answer
Answer:
B: Encouraging fluid intake of at least 200ml per hour
Rationale:
It is important to keep the client in sickle cell crisis hydrated to
prevent further sickling of the blood. Dehydration is a common
cause of sickling. Answer A is incorrect because a mechanical
cuff places too much pressure on the arm. Answer C is incorrect
because raising the knee gatch impedes circulation. Answer D is
incorrect because Tylenol is too mild an analgesic for the client
in crisis.
A 60-year-old comes into the emergency department with
crushing substernal chest pain that radiates to the shoulder and
left arm. The admitting diagnosis is acute myocardial infarction
(MI). Admission prescriptions include oxygen by nasal cannula
at 4 L/min, complete blood count (CBC), a chest radiograph, a
12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate
given IV. The nurse should first:
A. Administer the morphine
B. Obtain a 12-lead ECG
C. Obtain the blood work
,D. Prescribe the chest radiograph Correct Answer A.
Administer the morphine
Rationale: Although obtaining the ECG, chest radiograph, and
blood work are all important, the nurse's priority action should
be to relieve the crushing chest pain. Therefore, administering
morphine sulfate is the priority action.
A 68-year-old woman is diagnosed with thrombocytopenia due
to acute lymphocytic leukemia. She is admitted to the hospital
for treatment. The nurse should assign the patient:
A. to a private room so she will not infect other patients and
health care workers.
B. to a private room so she will not be infected by other patients
and health care workers.
C. to a semiprivate room so she will have stimulation during her
hospitalization.
D. to a semiprivate room so she will have the opportunity to
express her feelings about her illness. Correct Answer
Answer: B
What are the needs of the patient with acute lymphocytic
leukemia and thrombocytopenia?
Needed Info: Lymphocytic leukemia, disease characterized by
proliferation of immature WBCs. Immature cells unable to fight
infection as competently as mature white cells. Treatment:
chemotherapy, antibiotics, blood transfusions, bone marrow
transplantation. Nursing responsibilities: private room, no raw
fruits or vegs, small frequent meals, O2, good skin care.
,B. to a private room so she will not be infected by other patients
and health care workers - CORRECT: protects patient from
exogenous bacteria, risk for developing infection from others
due to depressed WBC count, alters ability to fight infection
A client comes into the emergency room with complaints of
sudden onset of severe right flank pain. While tests are being
performed, it is MOST important for the nurse to take which of
the following actions?
a) Make sure the the patient does not eat or drink anything
b) Strain all the patient's urine through several layers of gauze
c) Check the patient's grip strength and pupil reactivity
d) Send blood and urine specimens to the lab for analysis
Correct Answer B) Strain all the patient's urine through several
layers of gauze
Rationale: "b" is the correct answer. "MOST" indicates a
priority question. Symptoms suggest urinary caculi and should
strain urine for stone. Needed information: Symptoms of renal
calculi include- pain, diaphoresis, nausea and vomiting, fever
and chills, hematuria. Nursing care: monitor I&O and temp,
suggest increase in fluids, strain urine and check pH of urine,
and administer analgesics. Diet for prevention of stones:
consume foods low in calcium, sodium, and oxalates, avoid
vitamin D enriched foods, decrease purine sources, restrict citrus
fruits, milk, and potatoes.
A client had a right total hip arthroplasty 2 days ago. Which
precautions will the nurse teach the client to prevent surgical
complications? Select all that apply.
A. "Stand on your right leg to pivot to the chair"
, B. "Do not bend your leg more than 90 degrees"
C. "Cross your legs to be more comfortable"
D. "Avoid twisting your body when moving"
E. "Use a long-handled shoe horn to put on your shoes" Correct
Answer Correct Answers: B, D, and E
Rationale:
B, D, and E are proper ways to care for clients with THA. A and
C can lead to dislocation of the affected hip. Chart 18-3 on page
298 contains information on precautions, pain management, and
care for patients with THA
A client had surgery two (2) days ago and reports having a
moderate amount of pain, stating that it is "a 7 on a 1 to 10
scale" of intensity. What intervention has the highest priority in
the client's nursing care plan?
A. Encouraging diversional activities
B. Incorporating ADLs as soon as possible
C. Teaching key points of the relaxation response
D. Using preemptive analgesia Correct Answer Answer: D:
Using preemptive analgesia
Rationale:
Use of preemptive analgesia is a technique designed to decrease
pain in the postoperative period, decrease the requirements for a
postoperative analgesic, prevent morbidity, and decrease the
hospital stay.
A client has taken steroids for 12 years to help manage chronic
obstructive pulmonary disease (COPD). When making a home
