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Questions 158

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Extract:


Question 1 of 5

A child becomes neutropenic and is placed on protective isolation. The purpose of protective isolation is to:

Correct Answer: A

Rationale: The child no longer has normal white blood cells and is extremely susceptible to infection, necessitating protective isolation.

Question 2 of 5

A client is admitted for suspected bladder cancer. Which one of the following factors is most significant in the client's diagnosis?

Correct Answer: A

Rationale: Smoking is the most significant risk factor for bladder cancer, as tobacco toxins are excreted in urine, directly irritating the bladder lining.

Question 3 of 5

The nurse is caring for clients on a respiratory unit. Upon receiving the following client reports, which client should be seen first?

Correct Answer: C

Rationale: Edema and neck vein distention in a bronchitis client suggest right heart failure or cor pulmonale, requiring immediate assessment. Emphysema discharge (
A), antibiotics (
B), and abnormal PO2 (
D) are less urgent.

Question 4 of 5

A client with a history of chronic migraines is admitted with complaints of nausea. The nurse should give priority to:

Correct Answer: A

Rationale: Antiemetics relieve nausea in migraines, improving comfort and preventing dehydration.

Question 5 of 5

Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the rationale for this therapy is to:

Correct Answer: D

Rationale: Sodium polystyrene sulfonate (Kayexalate), a cation exchange resin, exchanges sodium ions for potassium ions in the large intestine reducing the serum potassium. Calcium is administered to protect the myocardium from the adverse effects of hyperkalemia. Serum levels reflect hyperkalemia. Rapid catabolism releases potassium from the body tissue into the bloodstream. Infection and hyperthermia increase the process of catabolism. The administration of dextrose and regular insulin IV forces potassium back into the cells decreasing the potassium in the serum.

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