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Questions 149

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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

A dexamethasone-suppression test has been ordered for a client with severe depression. The purpose of the dexamethasone suppression test is to:

Correct Answer: B

Rationale: The dexamethasone suppression test assesses cortisol suppression to evaluate hypothalamic-pituitary-adrenal axis dysfunction, aiding in diagnosing severe depression.

Question 3 of 5

Which laboratory test is used to identify injury to the myocardium and can remain elevated for up to 3 weeks?

Correct Answer: D

Rationale: Troponin T or I is highly specific for myocardial injury and can remain elevated for up to 2-3 weeks, making it the best marker for detecting cardiac damage.

Question 4 of 5

The nurse receives an order to administer 1,500 mL D5W IV over 12 hours. The drop factor is 15 drops/1 mL. The IV flow rate should be set at how many drops per minute? Round to the nearest whole number.

Correct Answer: 31

Rationale: Flow rate (drops/min) = (volume × drop factor) ÷ time. Calculation: (1,500 mL × 15 drops/mL) ÷ (12 × 60) = 22,500 ÷ 720 ≈ 31 drops/min.

Question 5 of 5

A nurse is giving instructions to parents of a child who had a tonsillectomy. Which instruction is the most important?

Correct Answer: C

Rationale: Avoiding straws prevents suction that could dislodge clots and cause bleeding, a critical post-tonsillectomy precaution.

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