Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast cancer. Which of the following findings should the nurse report to the provider?
A. WBC 1500/mm3
A WBC count of 1500/mm3 is significantly low (normal range is 4500-11000/mm3) and indicates neutropenia, placing the client at high risk for infection. This finding should be reported to the provider immediately.
B. RBC 5 million/mm3
An RBC count of 5 million/mm3 is within the normal range for females (4.2-5.4 million/mm3) and does not indicate an immediate concern in the context of chemotherapy.
C. Platelets 155,000/mm3
Platelet count of 155,000/mm3 is on the lower end of the normal range (150,000-450,000/mm3) but does not pose an immediate risk compared to neutropenia.
D. Hemoglobin 12 g/dL
A hemoglobin level of 12 g/dL is within the normal range for females (12-16 g/dL) and does not require urgent reporting.
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Full Explanation
A. A WBC count of 1500/mm3 is significantly low (normal range is 4500-11000/mm3) and indicates neutropenia, placing the client at high risk for infection. This finding should be reported to the provider immediately.
B. An RBC count of 5 million/mm3 is within the normal range for females (4.2-5.4 million/mm3) and does not indicate an immediate concern in the context of chemotherapy.
C. Platelet count of 155,000/mm3 is on the lower end of the normal range (150,000-450,000/mm3) but does not pose an immediate risk compared to neutropenia.
D. A hemoglobin level of 12 g/dL is within the normal range for females (12-16 g/dL) and does not require urgent reporting.
Similar Questions
A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect?
A. Hemorrhagic stroke
Hemorrhagic stroke is often associated with a sudden, severe headache, high blood pressure, and neurological symptoms such as seizures and vomiting due to the rupture of a blood vessel in the brain.
B. Thrombotic stroke
Thrombotic stroke is typically characterized by the gradual onset of symptoms due to a clot forming in an artery supplying the brain, not usually presenting with sudden severe headache and vomiting.
C. Transient ischemic attack (TIA)
Transient ischemic attack (TIA) presents with temporary neurological symptoms that resolve within 24 hours and does not usually involve seizures, severe headache, or significantly elevated blood pressure.
D. Embolic stroke
Embolic stroke occurs when a blood clot travels to the brain, leading to sudden onset of symptoms, but it is less commonly associated with the severe headache, vomiting, and hypertension seen in hemorrhagic stroke.
Full Explanation
A. Hemorrhagic stroke is often associated with a sudden, severe headache, high blood pressure, and neurological symptoms such as seizures and vomiting due to the rupture of a blood vessel in the brain.
B. Thrombotic stroke is typically characterized by the gradual onset of symptoms due to a clot forming in an artery supplying the brain, not usually presenting with sudden severe headache and vomiting.
C. Transient ischemic attack (TIA) presents with temporary neurological symptoms that resolve within 24 hours and does not usually involve seizures, severe headache, or significantly elevated blood pressure.
D. Embolic stroke occurs when a blood clot travels to the brain, leading to sudden onset of symptoms, but it is less commonly associated with the severe headache, vomiting, and hypertension seen in hemorrhagic stroke.
nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?
A. Lower the height of the solution container.
Lowering the height of the solution container will slow the rate of instillation, reducing the intensity of the cramps and allowing the client to tolerate the enema better.
B. Encourage the client to bear down.
Encouraging the client to bear down may increase discomfort and is not recommended during the administration of an enema.
C. Allow the client to expel some fluid before continuing.
Allowing the client to expel some fluid before continuing might provide temporary relief but does not address the rate of fluid instillation, which is the primary cause of cramping.
D. Stop the enema and document that the client did not tolerate the procedure.
Stopping the enema and documenting the intolerance is not the first step; adjusting the rate of administration should be tried first to help the client tolerate the procedure.
Full Explanation
A. Lowering the height of the solution container will slow the rate of instillation, reducing the intensity of the cramps and allowing the client to tolerate the enema better.
B. Encouraging the client to bear down may increase discomfort and is not recommended during the administration of an enema.
C. Allowing the client to expel some fluid before continuing might provide temporary relief but does not address the rate of fluid instillation, which is the primary cause of cramping.
D. Stopping the enema and documenting the intolerance is not the first step; adjusting the rate of administration should be tried first to help the client tolerate the procedure.
A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?
A. Include foods high in fiber.
While high-fiber foods are generally healthy, they are not specifically targeted to prevent biliary colic. The primary dietary focus should be on fat intake.
B. Avoid foods high in fat.
Avoiding foods high in fat is crucial for clients with chronic cholecystitis, as fatty foods can trigger biliary colic by stimulating the gallbladder to contract.
C. Avoid foods high in sodium.
High sodium intake is more related to cardiovascular and kidney health and is not specifically implicated in biliary colic.
D. Include foods high in starch and proteins.
Including foods high in starch and proteins is not as critical as avoiding fatty foods to prevent episodes of biliary colic.
Full Explanation
A. While high-fiber foods are generally healthy, they are not specifically targeted to prevent biliary colic. The primary dietary focus should be on fat intake.
B. Avoiding foods high in fat is crucial for clients with chronic cholecystitis, as fatty foods can trigger biliary colic by stimulating the gallbladder to contract.
C. High sodium intake is more related to cardiovascular and kidney health and is not specifically implicated in biliary colic.
D. Including foods high in starch and proteins is not as critical as avoiding fatty foods to prevent episodes of biliary colic.