A client has received platelet infusions. Which finding would indicate the most therapeutic effect from the transfusions?
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Solution
Answer D is correct. Platelets deal with the clotting of blood. Lack of platelets can cause bleeding. Answers A, B, and C do not directly relate to platelets.
The LPN/LVN is assisting a client immediately after a paracentesis. Which of the following actions is the priority?
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Solution
Answer A is correct. The client is at risk for a loss of fluid volume and shock, so obtaining the vital signs to assess for complications would be the priority. Answers B, C, and D can all be implemented, but they are not the priority so they are incorrect.
The nurse is caring for a client after a liver biopsy. The nurse should carefully monitor the client for the development of which of the following?
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Solution
Answer C is correct. The lung could be punctured inadvertently by the liver biopsy procedure, causing a pneumothorax. The nurse should also be alert for hemorrhage. Answers A, B, and D are not associated risks with a liver biopsy.
A client with end stage cirrhosis can sometimes develop mental changes. What is the most likely cause?
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Solution
Answer A is correct. The liver fails to convert protein for excretion; therefore, protein converts to ammonia, which then builds up in the blood stream, causing mental changes and sometimes coma. An increased WBC and high blood sugar are not associated with liver cirrhosis, so answers C and D are incorrect. The protein levels are elevated, as evidenced by elevated ammonia in the serum, so answer B is incorrect.
The nurse is preparing a client for cervical uterine radiation implant insertion. Which will be included in the nurse’s explanations?
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Solution
Answer B is correct. A catheter will allow urine elimination without possible disruption of the implant. There is usually no restriction on TV or phone use, as in answer A. The client is placed on a low-residue diet, not a high-fiber diet, as in answer C. The client’s radiation is not internal; therefore, there are no special precautions with excretions, as in answer D.
The nurse is discussing pain from cholecystitis with a client. Which statement made by the client most accurately describes the typical pain of this disorder?
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Solution
Answer C is correct. Clients with gallbladder (GB) disease complain of colicky pain usually after intake of fatty foods. The pain is located in the right upper quadrant of the abdomen or the right shoulder, so answer A is incorrect. Food intake causes more pain because of GB stimulation, so answer B is incorrect. Answer D is an incorrect statement because the gallbladder function is not associated with diarrhea or constipation.
The nurse caring for a client diagnosed with bone cancer is exhibiting mental confusion and a BP of 150/100. Which laboratory value would correlate with the client’s symptoms reflecting a common complication with this diagnosis?
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Solution
Answer B is correct. Hypercalcemia is a common occurrence with cancer of the bone. Clinical manifestations of hypercalcemia include mental confusion and an elevated blood pressure. The potassium level in answer A is elevated but does not relate to the diagnosis. Answers C and D are both normal levels.
Which comment made by a client with congestive heart failure should cause a need for nursing follow-up?
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Solution
Answer D is correct. This statement indicates that the client is retaining fluid and the condition is deteriorating. Answers A and B are normal and require no need for followup. Answer C indicates that the client is diuresing, which is a positive outcome of treatment.
A child is to receive heparin sodium 5 units per kilogram of body weight by subcutaneous route every 4 hours. The child weighs 52.8 lb. How many units should the child receive in a 24-hour period?
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Solution
Answer C is correct. The child weighs 24kg and should receive 5 units/kg, or 120 units every 4 hours. This would be 720 units in 24 hours. The answers in A, B, and D are incorrect calculations.
The nurse is caring for a client after a motor vehicle accident. The client has a fractured tibia, and bone is noted protruding through the skin. Which action would be the highest priority?
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Solution
Answer B is correct. The client has an open fracture. The priority would be to cover the wound and prevent further contamination. Swelling usually occurs with a fracture, making answer C incorrect. Manual traction, as in answer A, should not be attempted. In Answer D, the change in position would cause excessive movement and is an inappopriate action.