Question

A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching?

Answer 1

Correct Answers:

Aplastic anemia results from decreased bone marrow production of RBCs.

Rationale :

🟢 Bone marrow suppression leads to reduced production of RBCs, WBCs, and platelets, characteristic of aplastic anemia.

🟢 Pancytopenia results in fatigue, frequent infections, and bleeding tendencies.

🟢 Unlike pernicious anemia, this is not caused by vitamin B12 deficiency but by marrow failure.

🟢 Causes include autoimmune disorders, toxins, and certain drugs.

🟢 Treatment may involve immunosuppressive therapy or bone marrow transplantation.

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Answer 2

Correct Answers:

Have the client lie flat in bed.

Rationale :

🔵 Post-cardiac catheterization, lying flat reduces bleeding risk at the femoral puncture site.

🔵 Flexing the leg or sitting up increases pressure on the arterial site, risking hematoma or hemorrhage.

🔵 Immobilization for 4–6 hours allows adequate hemostasis.

🔵 Frequent neurovascular checks ensure limb perfusion.

🔵 Bleeding or hematoma formation is the most serious post-procedure complication.

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Answer 3

Correct Answers:

Hip arthroplasty

Rationale :

🟠 Orthopedic surgeries, especially hip or knee replacements, increase risk for DVT due to immobility.

🟠 Venous stasis occurs from limited mobility and trauma to vessels during surgery.

🟠 Prophylactic measures include anticoagulants, compression devices, and early ambulation.

🟠 Myringotomy and cataract extraction have minimal DVT risk due to early mobility.

🟠 Monitoring for calf pain, swelling, or warmth is essential postoperatively.

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Answer 4

Correct Answers:

Airway patency

Rationale :

🟡 Post-laryngectomy, airway maintenance is the highest priority (ABC principle).

🟡 Edema, bleeding, or mucus plugs can obstruct the airway postoperatively.

🟡 Continuous oxygen saturation monitoring is required.

🟡 Pain and tissue integrity are secondary to ensuring adequate ventilation.

🟡 Early airway compromise can be life-threatening.

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Answer 5

Correct Answers:

Smoking cessation

Rationale :

🔴 Smoking is the primary cause of chronic bronchitis due to chronic irritation of bronchi.

🔴 Cessation reduces airway inflammation and slows disease progression.

🔴 Exercise and weight control help but do not prevent chronic bronchitis if smoking continues.

🔴 Annual flu vaccine is important but targets infection prevention, not chronic bronchitis cause.

🔴 Early cessation improves lung function and quality of life.

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Answer 6

Correct Answers:

Intercostal retractions

Rationale :

🟢 Atelectasis with hypoxia increases work of breathing, causing retractions.

🟢 Retractions indicate use of accessory muscles due to impaired oxygen exchange.

🟢 Hypoxia also leads to tachypnea and restlessness, not bradypnea.

🟢 Untreated hypoxia can progress to lethargy and cyanosis.

🟢 Early respiratory interventions prevent respiratory failure.

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Answer 7

Correct Answers:

The laboratory values are prolonged.

Rationale :

🔵 In DIC, consumption of clotting factors causes prolonged PT, aPTT, and INR.

🔵 Widespread clotting depletes platelets and fibrinogen, leading to bleeding risk.

🔵 Early lab trends guide treatment with heparin or plasma products.

🔵 DIC progresses quickly, requiring continuous lab monitoring.

🔵 Prompt treatment reduces risk of multi-organ failure.

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Answer 8

Correct Answers:

Rifampin
Isoniazid
Pyrazinamide

Rationale :

🟠 First-line TB therapy uses these drugs in combination to prevent resistance.

🟠 Rifampin may cause red-orange body fluid discoloration.

🟠 Isoniazid can cause hepatotoxicity and peripheral neuropathy; vitamin B6 is given to prevent neuropathy.

🟠 Pyrazinamide is effective but also hepatotoxic; liver enzymes are monitored.

🟠 Combination therapy improves treatment success and reduces resistance.

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Answer 9

Correct Answers:

Place the client on his left side in Trendelenburg position.

Rationale :

🟢 Air embolism management uses left lateral Trendelenburg to trap air in the right atrium, preventing it from entering pulmonary circulation.

🟢 Immediate catheter clamping prevents further air entry.

🟢 High-flow oxygen may also be administered to reduce bubble size.

🟢 Removal of catheter is delayed until air is secured to prevent worsening embolism.

🟢 Early recognition is critical to prevent cardiovascular collapse.

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Answer 10

Correct Answers:

The fourth heart sound (S4)

Rationale :

🔴 S4 occurs before S1 and indicates stiff ventricular walls due to ventricular hypertrophy or ischemia.

🔴 It is often heard in conditions like hypertension or MI.

🔴 S3 occurs after S2 and indicates fluid overload or heart failure.

🔴 Identifying abnormal heart sounds aids in early cardiac dysfunction detection.

🔴 Further evaluation with echocardiogram may be warranted.

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QLexNursing

1 :
A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching?

2 :
A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?

3 :
A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis?

4 :
A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

5 :
A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder?

6 :
A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expert?

7 :
A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?

8 :
A nurse is teaching a client who has tuberculosis and is to start combination drug therapy. Which of the following medications should the nurse plan to administer? (Select all that apply.)

9 :
A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time?

10 :
A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?

QLexNursing

1 : A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching?

2 : A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?

3 : A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis?

4 : A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

5 : A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder?

6 : A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expert?

7 : A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?

8 : A nurse is teaching a client who has tuberculosis and is to start combination drug therapy. Which of the following medications should the nurse plan to administer? (Select all that apply.)

9 : A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time?

10 : A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?

1 :
A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching?

2 :
A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?

3 :
A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis?

4 :
A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

5 :
A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder?

6 :
A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expert?

7 :
A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?

8 :
A nurse is teaching a client who has tuberculosis and is to start combination drug therapy. Which of the following medications should the nurse plan to administer? (Select all that apply.)

9 :
A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time?

10 :
A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?