The nurse recognizes which of the following types of leukemia as being more common in an older adult?
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Solution
Answer C is correct. Two-thirds of the clients with chronic lymphocytic leukemia are older than 60 years of age at diagnosis. Answers A, B, and D do not occur more often in the elderly, so they are incorrect.
Which assessment data on a child with hydrocephalus would be the most objective?
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Solution
Answer C is correct. An increase in head growth is used as a diagnostic gauge for hydrocephalus. Answers A and B can also occur with hydrocephalus, but they are not as specific or diagnostic as head circumference, so they are incorrect. Answer D is not related to hydrocephalus, so it is incorrect.
The nurse caring for a client in shock recognizes that the glomerular filtration rate of the kidneys will remain intact if the client’s mean arterial pressure remains above which minimal value?
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Solution
Answer A is correct. Acute renal failure can occur when the MAP drops below 80. The mean arterial pressures in answers B, C, and D are too low to allow proper functioning of the kidney, which makes these answers incorrect.
The nurse is caring for a client with scalding burns across the face, neck, entire anterior chest, and entire right arm. Using the rule of nines, what is the estimated percentage of body burned?
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Solution
Answer C is correct. The rule of nines is a way to estimate the percentage of body surface area burned (see the following figure). The calculation would be 4.5% for the face and neck, 9% for the entire arm, and 18% for the entire anterior chest, which would be 31.5%, or approximately 32%. Answers A, B, and D are not correctly calculated sums of the burned areas.
Which technique is correct for administration of ear drops to a 3-year-old?
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Solution
Answer C is correct. Pulling the pinna down and back is correct for administering ear drops to a child because the child’s ear canal is short and straight. The pinna is pulled up and back for adults. Answers A and B are improper technique and would make it harder for the drops to be administered. Answer D would be incorrect because this is not a necessary part of administering ear drops, even though irrigation might be done at times to cleanse the ear for assessment.
The nurse notes the following laboratory test results on a 24-hour post-burn client. Which abnormality should be of particular concern?
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Solution
Answer A is correct. Normal potassium is 3.5–5.0. Severe life-threatening complications can occur with hyperkalemia, requiring the physician to be notified of any abnormality. Answers B, C, and D are normal results, which makes them incorrect.
Which antibiotic is safest to administer to a client who is allergic to penicillin?
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Solution
Answer C is correct. Erythromycin is the only drug listed that is not penicillin based. Answers A, B, and D are in the same family as penicillin, so they are not as safe to administer, which makes them incorrect.
The nurse is preparing to administer promethazine hydrochloride (Phenergan). This drug should produce which therapeutic effect?
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Solution
Answer B is correct. Phenergan is used for prevention and treatment of nausea and vomiting, sedation, adjunct to pain and anesthesia medications, and allergic reactions. Answers A, C, and D are not desired effects of the drug Phenergan, which makes them incorrect.
A burn client’s care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?
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Solution
Answer A is correct. A culture result that shows minimal bacteria is a favorable outcome. Answers B, C, and D are abnormal and negative outcomes, so they are incorrect.
A client with a gastrointestinal bleed has an NG tube to low continuous wall suction. To assess bowel sounds, the nurse should perform which of the following procedures?
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Solution
Answer B is correct. It is important to clamp the tube while auscultating because the sound from the suction interferes with the auscultation process. Answer A is one measure used to determine whether NG is in the stomach, but not to assess bowel sounds. Answers C and D are not the correct procedure for assessment of bowel sounds, so they are incorrect.