Question

A nurse is reviewing data for a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

Answer 1

Correct Answers:

Excessive thrombosis and bleeding.

Rationale :

✅ Disseminated Intravascular Coagulation (DIC) is characterized by both widespread clot formation and simultaneous bleeding due to the depletion of clotting factors and platelets.

✅ The body responds to triggers such as infection, trauma, or malignancy by producing microthrombi throughout the vasculature.

✅ This leads to organ ischemia and consumption of platelets and coagulation proteins.

✅ As the body runs out of these factors, the client becomes prone to spontaneous bleeding, especially from mucous membranes and IV sites.

✅ Monitoring for bleeding and clotting signs is a nursing priority.

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Answer 2

Correct Answers:

A client who has severe respiratory stridor and a deviated trachea.

Rationale :

◼️ A client with stridor and tracheal deviation is experiencing a life-threatening airway obstruction, likely due to tension pneumothorax or upper airway swelling.

◼️ This condition requires immediate airway support to prevent respiratory arrest.

◼️ In a mass casualty scenario, airway compromise is treated as the top priority following the ABCs (Airway, Breathing, Circulation).

◼️ The other clients, though injured, are more stable in comparison.

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Answer 3

Correct Answers:

"Russell's traction uses a sling under the knee to treat a fracture of the femur."

Rationale :

♦️ Russell's traction is a type of skin traction that incorporates a knee sling to suspend the leg and apply longitudinal pull for femoral or hip fractures.

♦️ This method allows for immobilization while reducing muscle spasms and maintaining proper alignment.

♦️ It also facilitates limited movement of the hip and knee, which prevents joint stiffness during long-term treatment.

♦️ The setup involves weights and pulleys without invasive skeletal pins.

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Answer 4

Correct Answers:

Place the client in a private room with a special ventilation system.

Rationale :

💎 Active laryngeal tuberculosis (TB) is transmitted through airborne droplets, requiring airborne precautions.

💎 The client must be placed in a negative-pressure room to prevent the spread of infection.

💎 Visitors and staff must wear N95 respirators when entering the room.

💎 Strict adherence to these measures helps prevent nosocomial transmission.

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Answer 5

Correct Answers:

"Please call for assistance when you wish to get out of bed."

Rationale :

✔️ Ménière’s disease affects the inner ear and can lead to sudden vertigo, tinnitus, and balance issues.

✔️ Due to the risk of falls during vertigo attacks, clients must avoid unassisted ambulation.

✔️ Calling for assistance minimizes injury risk and helps monitor changes in symptoms.

✔️ Safety precautions are vital to prevent fractures or head trauma.

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Answer 6

Correct Answers:

Avoid crowded places.

Rationale :

🔹 Neutropenic clients are highly susceptible to infections due to low neutrophil counts.

🔹 Avoiding crowded areas reduces the risk of exposure to airborne and contact-based pathogens.

🔹 Clients should also avoid sick contacts and maintain strict hand hygiene.

🔹 Additional teaching includes avoiding raw foods and closely monitoring for infection signs.

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Answer 7

Correct Answers:

Limit the number of health care workers entering the room.

Rationale :

◈ Clients who are immunosuppressed require environmental controls to prevent exposure to infectious agents.

◈ Limiting traffic in the room helps reduce the introduction of pathogens from healthcare staff.

◈ This is especially critical after chemotherapy, when immune defenses are significantly compromised.

◈ Other infection prevention includes hand hygiene, PPE, and no fresh flowers or unwashed produce.

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Answer 8

Correct Answers:

Wear a mask while out or around crowds of people.

Rationale :

⬛ A client with active pulmonary TB remains infectious until confirmed non-contagious by sputum results.

⬛ Wearing a mask in public settings prevents the spread of TB bacilli via respiratory droplets.

⬛ This is part of airborne precautions and essential for community safety.

⬛ Education should emphasize medication adherence and follow-up testing.

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Answer 9

Correct Answers:

The client should wear dark glasses while outdoors.

Rationale :

⬥ After cataract surgery, the eyes are sensitive to light due to the absence of the cloudy lens.

⬥ Wearing dark sunglasses reduces glare, discomfort, and UV exposure, which can impede healing.

⬥ Clients should also avoid straining and bending over to prevent pressure on the operative eye.

⬥ This teaching supports comfort and prevents complications like retinal detachment.

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Answer 10

Correct Answers:

Sun exposure as a child is a significant risk factor for skin cancer.

Rationale :

⬙ Ultraviolet (UV) exposure during childhood causes cumulative damage to skin cells, predisposing individuals to skin cancers later in life.

⬙ This includes basal cell carcinoma, squamous cell carcinoma, and melanoma.

⬙ Prevention includes sun protection from a young age—sunscreen, hats, and limited exposure.

⬙ Education should highlight early detection of suspicious lesions.

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QLexNursing

1 :
A nurse is reviewing data for a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

2 :
A nurse is assisting with triaging clients after a mass casualty event. Which of the following clients should the nurse attend to first?

3 :
A nurse is reinforcing teaching about Russell's traction with a newly licensed nurse. Which of the following statements should the nurse make?

4 :
A nurse is caring for a client who is suspected to have active laryngeal tuberculosis (TB). Which of the following actions should the nurse plan to take to safely care for this client?

5 :
A nurse is caring for a client who has Ménière’s disease. When asked by the client if he is allowed to ambulate independently, which of the following responses should the nurse make?

6 :
A nurse is reinforcing teaching with a client who has neutropenia. Which of the following instructions should the nurse include in the teaching?

7 :
A nurse is assisting in the plan of care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?

8 :
A nurse is preparing to review discharge instructions with a client who has pulmonary tuberculosis. Which of the following information should the nurse include?

9 :
A nurse at an outpatient surgery center is reinforcing discharge teaching with a client’s partner following surgical removal of a cataract. Which of the following information should the nurse include in the teaching?

10 :
A nurse in a health clinic is assisting in the planning of an educational program on skin cancer. Which of the following statements should be included in the presentation?

QLexNursing

1 : A nurse is reviewing data for a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

2 : A nurse is assisting with triaging clients after a mass casualty event. Which of the following clients should the nurse attend to first?

3 : A nurse is reinforcing teaching about Russell's traction with a newly licensed nurse. Which of the following statements should the nurse make?

4 : A nurse is caring for a client who is suspected to have active laryngeal tuberculosis (TB). Which of the following actions should the nurse plan to take to safely care for this client?

5 : A nurse is caring for a client who has Ménière’s disease. When asked by the client if he is allowed to ambulate independently, which of the following responses should the nurse make?

6 : A nurse is reinforcing teaching with a client who has neutropenia. Which of the following instructions should the nurse include in the teaching?

7 : A nurse is assisting in the plan of care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?

8 : A nurse is preparing to review discharge instructions with a client who has pulmonary tuberculosis. Which of the following information should the nurse include?

9 : A nurse at an outpatient surgery center is reinforcing discharge teaching with a client’s partner following surgical removal of a cataract. Which of the following information should the nurse include in the teaching?

10 : A nurse in a health clinic is assisting in the planning of an educational program on skin cancer. Which of the following statements should be included in the presentation?

1 :
A nurse is reviewing data for a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

2 :
A nurse is assisting with triaging clients after a mass casualty event. Which of the following clients should the nurse attend to first?

3 :
A nurse is reinforcing teaching about Russell's traction with a newly licensed nurse. Which of the following statements should the nurse make?

4 :
A nurse is caring for a client who is suspected to have active laryngeal tuberculosis (TB). Which of the following actions should the nurse plan to take to safely care for this client?

5 :
A nurse is caring for a client who has Ménière’s disease. When asked by the client if he is allowed to ambulate independently, which of the following responses should the nurse make?

6 :
A nurse is reinforcing teaching with a client who has neutropenia. Which of the following instructions should the nurse include in the teaching?

7 :
A nurse is assisting in the plan of care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?

8 :
A nurse is preparing to review discharge instructions with a client who has pulmonary tuberculosis. Which of the following information should the nurse include?

9 :
A nurse at an outpatient surgery center is reinforcing discharge teaching with a client’s partner following surgical removal of a cataract. Which of the following information should the nurse include in the teaching?

10 :
A nurse in a health clinic is assisting in the planning of an educational program on skin cancer. Which of the following statements should be included in the presentation?