Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm.
Which of the following actions should the nurse take?
A. Apply pressure to venipuncture sites for 10 min.
Choice A Applying pressure to venipuncture sites for 10 min is not necessary for a low WBC count.
B. Move the client to a negative pressure room.
Choice B Moving the client to a negative pressure room is not necessary for a low WBC count.
C. Instruct the client to avoid eating raw fruit.
Instruct the client to avoid eating raw fruit. A low white blood cell count can be caused by cancer or cancer treatment and can increase the risk of infection. One precaution that can be taken is to avoid all pre-cut fresh fruits and vegetables in delis, restaurants, and grocery stores.
D. Use contact isolation while providing care.
Choice D Contact isolation while providing care is not necessary for a low WBC count.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Adult Medical Surgical 2019 Proctored Exam. Take the full exam now
Full Explanation
Instruct the client to avoid eating raw fruit.
A low white blood cell count can be caused by cancer or cancer treatment and can increase the risk of infection.
One precaution that can be taken is to avoid all pre-cut fresh fruits and vegetables in delis, restaurants, and grocery stores.
Choice A Applying pressure to venipuncture sites for 10 min is not necessary for a low WBC count.
Choice B Moving the client to a negative pressure room is not necessary for a low WBC count.
Choice D Contact isolation while providing care is not necessary for a low WBC count.
Similar Questions
A nurse in an emergency department is preparing a client for emergency surgery.
The client's blood alcohol level is 180 mg/dL.
Which of the following actions is the nurse's priority?
A. Insert an indwelling urinary catheter.
Inserting an indwelling urinary catheter may be necessary for monitoring urine output in some cases, but in this situation, the priority is to insert an NG tube. This will help prevent aspiration during surgery due to the client's high blood alcohol level, which increases the risk of vomiting.
B. Insert an NG tube.
Inserting an NG tube is the priority action for the nurse because a high blood alcohol level increases the risk of vomiting and aspiration during surgery. An NG tube can help reduce this risk by keeping the stomach empty and minimizing the chance of aspiration.
C. Obtain consent for surgery.
Obtaining consent for surgery is important, but in emergency situations, consent may be implied, or a designated surrogate decision-maker may provide consent. It is not the priority action for the nurse in this scenario.
D. Apply antiembolic stockings.
Applying antiembolic stockings is a preventive measure for deep vein thrombosis, but it is not the priority action in this case. Ensuring the client's safety during surgery, specifically by preventing aspiration, takes precedence due to the client's high blood alcohol level.
Full Explanation
The correct answer is choice B: Insert an NG tube.
Choice A rationale: Inserting an indwelling urinary catheter may be necessary for monitoring urine output in some cases, but in this situation, the priority is to insert an NG tube. This will help prevent aspiration during surgery due to the client's high blood alcohol level, which increases the risk of vomiting.
Choice B rationale: Inserting an NG tube is the priority action for the nurse because a high blood alcohol level increases the risk of vomiting and aspiration during surgery. An NG tube can help reduce this risk by keeping the stomach empty and minimizing the chance of aspiration.
Choice C rationale: Obtaining consent for surgery is important, but in emergency situations, consent may be implied, or a designated surrogate decision-maker may provide consent. It is not the priority action for the nurse in this scenario.
Choice D rationale: Applying antiembolic stockings is a preventive measure for deep vein thrombosis, but it is not the priority action in this case. Ensuring the client's safety during surgery, specifically by preventing aspiration, takes precedence due to the client's high blood alcohol level.
A nurse is preparing to administer furosemide to a client who has acute heart failure.
Which of the following laboratory results should the nurse identify as a contraindication for receiving the medication?
A. Sodium 136 mEq/L.
Sodium 136 mEq/L is within the normal range and is not a contraindication for receiving furosemide.
B. Creatinine 0.8 mg/dL.
B) Creatinine 0.8 mg/dL is within the normal range and is not a contraindication for receiving furosemide.
C. Potassium.2 mEq/L.
Furosemide is a loop diuretic that can cause loss of potassium from the body. A potassium level of.2 mEq/L is considered low (hypokalemia) and can be a contraindication for receiving the medication.
D. BUN 18 mg/dL.
D) BUN 18 mg/dL is within the normal range and is not a contraindication for receiving furosemide.
Full Explanation
Furosemide is a loop diuretic that can cause loss of potassium from the body.
A potassium level of.2 mEq/L is considered low (hypokalemia) and can be a contraindication for receiving the medication.
Sodium 136 mEq/L is within the normal range and is not a contraindication for receiving furosemide.
B) Creatinine 0.8 mg/dL is within the normal range and is not a contraindication for receiving furosemide.
D) BUN 18 mg/dL is within the normal range and is not a contraindication for receiving furosemide.
A nurse is caring for a client who has chronic renal failure.
The client displays the following ABG results: pH 7.24, PaCO2 44 mm Hg, PaO2 84 mm Hg. HCO3 18 mEq/L, base excess -2, and O2 saturation 95%.
The nurse should conclude that the client has which of the following acid-base imbalances?
A. Respiratory acidosis.
Respiratory acidosis is not indicated by the ABG results as the PaCO2 is within the normal range.
B. Metabolic alkalosis.
B) Metabolic alkalosis is not indicated by the ABG results as the pH and HCO3 levels are below their respective normal ranges.
C. Respiratory alkalosis.
C) Respiratory alkalosis is not indicated by the ABG results as the pH is below the normal range and the PaCO2 is within the normal range.
D. Metabolic acidosis.
The client’s ABG results show a pH of 7.24, which is below the normal range of 7.35-7.45 and indicates acidosis. The PaCO2 is within the normal range of 35-45 mm Hg, indicating that the acidosis is not caused by a respiratory issue. The HCO3 level is 18 mEq/L, which is below the normal range of 22-28 mEq/L and indicates a primary metabolic cause for acidosis.
Full Explanation
The client’s ABG results show a pH of 7.24, which is below the normal range of 7.35-7.45 and indicates acidosis.
The PaCO2 is within the normal range of 35-45 mm Hg, indicating that the acidosis is not caused by a respiratory issue.
The HCO3 level is 18 mEq/L, which is below the normal range of 22-28 mEq/L and indicates a primary metabolic cause for acidosis.
Respiratory acidosis is not indicated by the ABG results as the PaCO2 is within the normal range.
B) Metabolic alkalosis is not indicated by the ABG results as the pH and HCO3 levels are below their respective normal ranges.
C) Respiratory alkalosis is not indicated by the ABG results as the pH is below the normal range and the PaCO2 is within the normal range.