The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation, so the statement to drink less than 500mL is incorrect. Options B, C, and D: Support hose promotes venous return, the electric razor prevents bleeding due to injury, and a diet low in iron is essential to preventing further red cell formation.
IV glucocorticoids raise the glucose levels and often require coverage with insulin. Options B, C, and D: Intake/output measurements is not necessary at this time, sodium and potassium levels would be monitored when the client is receiving mineralocorticoids, and daily weights is unnecessary.
Furosemide, a loop diuretic, does not alter pain. Option A: Furosemide acts on the kidneys to increase urinary output. Option B: Fluid may move from the periphery, decreasing edema. Option D: Fluid load is reduced, lowering blood pressure.
The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Options A, C, and D: Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations.
Symptoms of Hodgkin's disease include night sweats, fatigue, weakness, and tachycardia. Option A: The disease is characterized by painless, enlarged cervical lymph nodes. Option C: Nausea and vomiting are not typically symptoms of Hodgkin's disease. Option D: Weight loss occurs early in the disease.
Furosemide, a loop diuretic, does not alter pain. Option A: Furosemide acts on the kidneys to increase urinary output. Option B: Fluid may move from the periphery, decreasing edema. Option D: Fluid load is reduced, lowering blood pressure.
Platelet counts under 30,000/microliter may cause spontaneous petechiae and bruising, particularly in the extremities. When the count falls below 15,000, spontaneous bleeding into the brain and internal organs may occur. Headaches may be a sign and should be watched for. Options B and D: Thrombocytopenia does not compromise immunity, and there is no reason to limit visitors as long as any physical trauma is prevented. Option C: Aspirin disables platelets and should never be used in the presence of thrombocytopenia.
The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices; therefore, answers A, B, and C are incorrect.
It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Options A, B, and C: Body temperature, motion, and sensation would not give information regarding peripheral circulation.
Protamine sulfate is given to counteract the effects of enoxaparin as well as heparin. Calcium gluconate is given to counteract the effects of magnesium sulfate; therefore, answer A is incorrect. Answer B is incorrect because aquamephyton is given to counteract the effects of sodium warfarin. Answer C is incorrect because methergine is given to increase uterine contractions following delivery.
Participating in reality orientation is the most appropriate activity for the client who is confused. Answers B, C, and D are incorrect because they are not suitable activities for a client who is confused.
The nurse should recommend acetaminophen for the child’s joint discomfort because it will have no effect on the bleeding time. Answers A, C, and D are all nonsteroidal anti-inflammatory medications that can prolong bleeding time; therefore, they are not suitable for the child with hemophilia.
Applying a paste of baking soda and water soothes the itching and helps to dry the vesicles. The use of baby powder is not recommended for either children; therefore, answer A is incorrect. Answers B and C are incorrect because hydrogen peroxide and saline will not relieve the itching and will prevent the vesicles from crusting.
The infant with hypospadias has altered patterns of urinary elimination caused by the location of the urinary meatus on the dorsum, or underside, of the penis. Answer B is incorrect because it refers to ureteral reflux. Answer C is incorrect because it refers to epispadias. Answer D is incorrect because it refers to exstrophy of the bladder.
Zantac (ranitidine) should be administered in one dose at bedtime or with meals. Answers A, B, and C have incorrect times for dosing.
Pain associated with angina is relieved by rest. Answer B is incorrect because it is not a true statement. Answer C is incorrect because pain associated with angina can be referred to the jaw, the left arm, and the back. Answer D is incorrect because pain from a myocardial infarction can be referred to areas other than the left arm.
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NCLEX-RN Test #11
