A client with thrombocytopenia secondary to leukemia develops epistaxis. The nurse should instruct the client to:

Correct Answer: B

Rationale: The correct answer is B: Sit upright, leaning slightly forward. This position helps to minimize blood flow to the head, reducing the risk of increased bleeding. It also prevents blood from flowing down the throat, reducing the risk of aspiration. A: Lying supine with the neck extended can increase pressure on the blood vessels in the head, potentially worsening the epistaxis. C: Blowing the nose and putting lateral pressure can disrupt any clots that may have formed and increase bleeding. D: Holding the nose while bending forward at the waist can lead to blood flowing down the throat and increase the risk of aspiration.

Correct Answer: C

Rationale: The correct answer is C: Comparing the patient’s present weight with her last weight. This is the most direct and reliable method to assess volume depletion due to fluid loss. By comparing the patient's current weight with her last weight, you can easily determine if there has been a significant decrease in weight indicating fluid loss and potential hypovolemia. Explanation of why other choices are incorrect: A: Measuring the quantity and specific gravity of her urine output - This method may provide some information about hydration status, but it is not as direct or reliable as comparing weight changes. B: Taking her blood pressure - While blood pressure can indicate hypovolemia, it may not provide immediate insight into volume depletion caused by diarrhea. D: Administering the oral water test - This test is not commonly used to assess volume depletion and may not be as effective or quick as comparing weight changes.

Correct Answer: A

Rationale: The correct answer is A: Trousseau's sign. This involves carpal spasm induced by inflating a blood pressure cuff above systolic pressure, indicating hypocalcemia. The nurse should monitor for this sign in clients at risk for low calcium levels. Hypoglycemia and hypokalemia have specific signs and symptoms not related to Trousseau's sign. Respiratory changes are nonspecific and may not be directly related to monitoring for low calcium levels.

Correct Answer: C

Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This inference is supported by the subjective data provided. Choice A is incorrect as it assumes the patient's fear is related to dressing changes, not discharge. Choice B is incorrect as resuming medications is not linked to the patient's fear of being alone. Choice D is incorrect as there is no indication in the scenario that the surgery was unsuccessful.

Correct Answer: C

Rationale: The correct answer is C: 0.90% sodium chloride. When administering a hypotonic solution like 0.45% sodium chloride or 5% dextrose in water, water moves into the cells causing them to swell. This can exacerbate symptoms of hypovolemia such as low blood pressure and decreased perfusion. However, 0.90% sodium chloride is an isotonic solution and will not further exacerbate hypovolemic symptoms. Choices A, B, and D are hypotonic solutions that can worsen hypovolemic symptoms by causing cellular swelling.

Correct Answer: B

Rationale: The correct answer is B: 17 drops per minute. To calculate the correct drip rate, you need to use the formula: (Volume to be infused in mL / Time in minutes) x Drop factor. In this case, if the volume to be infused is 100 mL and the time is 60 minutes with a drop factor of 20, the calculation would be: (100 / 60) x 20 = 33.33 drops per minute. Since we cannot deliver fractional drops, the closest whole number is 17 drops per minute. This ensures the correct delivery rate for the medication. Choice A (6 drops per minute) is incorrect as it would be too slow and may not deliver the medication effectively. Choice C (50 drops per minute) and Choice D (100 drops per minute) are incorrect as they would both deliver the medication too quickly, potentially causing harm to the patient. The correct answer, 17 drops per minute, ensures a safe and accurate delivery rate

Correct Answer: D

Rationale: The correct answer is D because testing the 4th (trochlear) and 6th (abducens) cranial nerves involves assessing eye movements. The trochlear nerve controls downward and inward eye movement, while the abducens nerve controls lateral eye movement. Asking the patient to follow the finger with their eyes tests the function of both nerves simultaneously. Choices A, B, and C do not specifically target the 4th and 6th cranial nerves, making them incorrect options.

Correct Answer: B

Rationale: The correct answer is B because a client's medical history of allergy to iodine or seafood is crucial for urinary diversion assessment to prevent potential adverse reactions during procedures involving contrast media or seafood-based medications. It is essential to ensure the client's safety and avoid any allergic reactions. Choice A is incorrect because assessing sexual function is not directly related to urinary diversion assessment. Choice C is also incorrect as urinary diversion does not typically affect nervous control. Choice D is irrelevant to the assessment of a client undergoing urinary diversion.

Correct Answer: D

Rationale: The correct answer is D: Passive immunization. This involves administering pre-formed antibodies to provide immediate protection. In the case of a pregnant client needing temporary protection from chickenpox, passive immunization is necessary as it offers immediate immunity without stimulating the client's immune system. - A (Naturally acquired active immunization): This involves exposure to the pathogen and the body producing its antibodies, which takes time and is not suitable for immediate protection. - B (Artificially acquired passive immunization): This option doesn't involve providing pre-formed antibodies, which are needed for immediate protection. - C (Artificially acquired active immunization): This method requires time for the body to develop its immunity, not providing immediate protection as needed in this scenario.