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NURS401 Exam 3 – Questions And Detailed Solutions
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NURS401 Exam 3 – Questions And Detailed Solutions
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NURS 401 Exam 1 – Questions & Accurate SolutionsA nurse is caring for a client with sickle cells disease. Which nursing action is
most effective in reducing potential for sepsis in this client
a. check vitals every 4 hours
b. perform frequent and thorough hand washing
c. administer prophylactic drug therapy
d. monitor for abnormal laboratory values Right Ans - b. Perform frequent
and thorough hand washing
The most effective nursing action to reduce the risk for sepsis in a client with
sickle cell anemia is to perform frequent and thorough handwashing.
Prevention and early detection strategies are used to protect the client in
sickle cell crisis from infection. Frequent and thorough handwashing is of the
utmost importance.
Taking vital signs every 4 hours will help with early detection of infection but
is not prevention. Drug therapy is a major defense against infections that
develop in the client with sickle cell disease but is not the most effective way
that the nurse can reduce the potential for sepsis. Continually assessing the
client for infection and monitoring the daily complete blood count with
differential white blood cell count is early detection, not prevention.
Which nursing intervention most effectively protects a client with
thrombocytopenia
a. take rectal temperatures
b. avoid use of dentures
c. encourage use of an electric shaver
d. apply warm compresses on trauma sites Right Ans - c. encourage use of
electric razor
The most effective nursing intervention that protects a client with
thrombocytopenia is encouraging the client to use an electric shaver. This
client must be advised to use an electric shaver instead of a razor. Any small
cuts or nicks can cause problems because of the prolonged clotting time.
To prevent rectal trauma, rectal thermometers would not be used. Oral or
tympanic temperatures would be taken. Dentures may be used by clients with
,thrombocytopenia as long as they fit properly and do not rub. Ice (not heat)
would be applied to areas of trauma.
A client with leukemia is being discharged from the hospital. The nurse's
discharge instructions say to keep regularly scheduled follow-up primary
health care provider appointments. The client says, "I don't have
transportation." Which is the most appropriate nursing response?
a. You can take the bus
b. I may be able to take you
c. the local American Cancer Society may be able to help
d. a pharmaceutical company might be able to help Right Ans - c. the local
American cancer society may be able to help
The most appropriate nursing response to the client who does not have
transportation for follow-up appointments is that "the local American Cancer
Society may be able to help." Many local units of the American Cancer Society
offer free transportation to clients with cancer, including those with leukemia.
Telling the client to take the bus is dismissive and does not take into
consideration the client's situation (e.g., the client may live nowhere near a
bus route). Although the nurse offering to take the client is compassionate, it
is not appropriate for the nurse to offer the client transportation. Suggesting a
pharmaceutical company is not the best answer. Drug companies typically do
not provide this type of service.
Which client statement indicates in-home stem cell transplantation is not a
viable option?
a. I was a nurse, so I can take care of myself
b. I don't feel strong enough, but my wife said she would help
c. We live 5 miles from the hospital
d. I will have lots of medicine to take Right Ans - a. I was a nurse so I can
take care of myself
The client statement that indicates that in-home stem cell transplantation is
not a viable option is "I was a nurse, so I can take care of myself." Stem cell
transplantation in the home setting requires support, assistance, and
coordination from others. The client cannot manage this type of care on his
own.
,It is acceptable for the client's spouse to support the client undergoing this
procedure. It is not unexpected for the client to be taking several
prescriptions. Five miles is an acceptable distance from the hospital, in case of
emergency.
The nurse is to administer packed red blood cells to a client. How does the
nurse ensure proper client identification?
a. Check the client's armband
b. Review all information with another registered nurse (RN)
c. Ask the client's name
d. Verify the client's room number Right Ans - b. review all information
with another registered nurse (RN)
With another registered nurse, all information must be reviewed. This process
includes verifying the client by name and number, checking blood
compatibility, and noting the expiration time. Human error is the most
common cause of ABO incompatibility reactions, even for experienced nurses.
Asking the client's name and checking the client's armband are not adequate
for identifying the client before transfusion therapy. Using the room number
to verify client identification is never appropriate.
What is the most important environmental risk for developing leukemia?
a. Living near high-voltage power lines
b. Direct contact with others with leukemia
c. Smoking cigarettes
d. Family history Right Ans - c. Smoking cigarettes
The most important environmental risk for developing leukemia is smoking
cigarettes. According to the American Cancer Society (ACS), the only proven
lifestyle-related risk factor for leukemia is cigarette smoking.
Genetics is a strong indicator, but it is not an environmental risk factor.
According to the ACS, living near high-voltage power lines is not a proven risk
factor for leukemia. Leukemia is not contagious.
A client who has been newly diagnosed with leukemia is admitted to the
hospital. Avoiding which potential problem takes priority in the client's
nursing care plan?
, a. Fluid overload (overhydration)
b. Hemorrhage
c. Infection
d. Hypoxia Right Ans - c. infection
Avoiding infection is the priority potential problem when caring for a newly
diagnosed client with leukemia.
Fluid overload, hemorrhage, and hypoxia are not priority problems for the
client with leukemia.
The nurse is assessing the endurance level of a client in a long-term care
facility. What question does the nurse ask to get this information?
a. "Are your feet or hands cold, even when you are in bed?"
b. "How much exercise do you get?"
c. "Do you feel more tired after you get up and go to the bathroom?"
d. "What is your endurance level?" Right Ans - c. do you feel more tired
after you get up and go to the bathroom
Asking about feeling tired after using the bathroom is the best question to ask
to assess a client's endurance level. This question is pertinent to the client's
activity and provides a comparison. The specific activity helps the client relate
to the question and provides needed answers.
The hospitalized client typically does not get much exercise. This would be a
difficult assessment for a client in long-term care facility to make. Asking the
client about his or her endurance level is too vague. The client may not know
how to answer this question. Asking about cold feet or hands does not address
the client's endurance.
The nurse is teaching a client with vitamin B12 deficiency anemia about
dietary intake. Which type of food does the nurse encourage the client to eat?
a. Grains
b. Leafy vegetables
c. Starchy vegetables
d. Dairy products Right Ans - d. Dairy products
The nurse encourages the client to eat dairy products such as milk, cheese,
and eggs. These foods will provide the vitamin B12 that the client needs.
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