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Questions 149

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Extract:


Question 1 of 5

Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?

Correct Answer: B

Rationale: Thrombocytopenia in acute leukemia increases the risk of bleeding, making 'risk for injury' the priority diagnosis to ensure patient safety.

Question 2 of 5

The nurse is caring for an organ donor client with a severe head injury from an MVA. Which of the following is most important when caring for the organ donor client?

Correct Answer: A

Rationale: Maintaining BP at 90 mmHg or greater ensures organ perfusion, critical for organ viability in a donor. Normal temperature and adequate urine output are important, but BP is the priority. Low hematocrit is not a goal.

Question 3 of 5

When assessing the urinary output of a client who has had extracorporeal lithotripsy, the nurse can expect to find:

Correct Answer: A

Rationale: Extracorporeal lithotripsy breaks up kidney stones, leading to cherry-red urine from minor bleeding that clears as healing progresses.

Question 4 of 5

An RN is working with an LPN to care for a group of clients. Which client would the RN most likely assign to the LPN?

Correct Answer: D

Rationale: The client requiring dressing changes is stable and within the LPN's scope of practice, whereas the other clients require advanced monitoring or interventions suitable for an RN.

Question 5 of 5

Which nursing assessment indicates that involutional changes have occurred in a client who is 3 days postpartum?

Correct Answer: A

Rationale: A firm fundus 3 finger widths below the umbilicus by day 3 postpartum indicates normal uterine involution, as the uterus shrinks progressively after delivery.

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