A nurse is caring for a client who is receiving chemotherapy. The client's platelet count is 25,000/mm3. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: Clients with a low platelet count are at risk of bleeding and infection. Monitoring the client's temperature every 4 hours is crucial to detect early signs of infection, as they may not be able to mount a typical immune response due to their compromised platelet count. Administering aspirin (choice A) is contraindicated in clients with low platelet counts as it can further increase the risk of bleeding. Monitoring urine output (choice C) and checking for stool in a colostomy bag (choice D) are important aspects of care but are not the priority in a client with low platelet count.

Correct Answer: A

Rationale: A heart rate of 78/min is within the normal range; however, postoperative patients require close monitoring for any signs of complications. While the heart rate is normal, other critical findings such as increased pain, excessive bleeding, or other concerning symptoms may need immediate attention. Choices B, C, and D all indicate normal postoperative vital signs and oxygen saturation levels, which do not raise immediate concerns requiring reporting to the provider.

Correct Answer: A

Rationale: The correct answer is A. Taking the pulse before taking digoxin is crucial as it helps monitor the heart rate, as digoxin can cause bradycardia as a side effect. Option B is incorrect because digoxin should be taken on an empty stomach to enhance absorption. Option C is incorrect because digoxin should be held and the healthcare provider should be contacted if the heart rate is less than 60/min. Option D is incorrect because digoxin should not be taken with food due to decreased absorption.

Correct Answer: B

Rationale: The correct answer is to avoid exposing the irradiated area to direct sunlight. Direct sunlight can further damage the skin during radiation therapy. Choice A is incorrect because alcohol-based lotions can irritate the skin further. Choice C is incorrect because mild soap and water can be drying to the skin. Choice D is incorrect because applying ice packs can cause additional skin damage during radiation therapy.

Correct Answer: D

Rationale: The correct answer is D: Hyperkalemia. In chronic kidney disease, there is decreased renal excretion of potassium, leading to elevated serum potassium levels. Hypokalemia (Choice A) is low potassium levels, which is the opposite finding in this scenario. Hypocalcemia (Choice B) is decreased calcium levels and is not directly related to chronic kidney disease or elevated potassium levels. Hypoglycemia (Choice C) is low blood sugar levels and is not typically associated with chronic kidney disease or high potassium levels.

Correct Answer: B

Rationale: The correct action for the nurse to take is to assess the client's lung sounds before administering IV fluids. This is crucial to identify any signs of fluid overload, such as crackles or wheezes. Administering the solution slowly over 24 hours (choice A) is not appropriate for an IV bolus, which is a rapid infusion. Changing the IV tubing every 12 hours (choice C) is a standard practice for preventing infection but is not directly related to administering an IV bolus. Flushing the IV line with heparin every 4 hours (choice D) is a maintenance practice to prevent clot formation in the line, not specifically related to administering an IV bolus.

Correct Answer: D

Rationale: The correct answer is D: 'You should keep your newborn's head elevated while they sleep.' Keeping the newborn's head elevated while sleeping helps prevent conditions like sudden infant death syndrome (SIDS). Choice A is incorrect because newborns do not need to be bathed every day; it is recommended to bathe them 2-3 times a week. Choice B is incorrect as heavy blankets can increase the risk of suffocation for newborns. Choice C is incorrect as newborn stools are typically soft and yellow in color, not firm and light brown.

Correct Answer: A

Rationale: The correct answer is A: 'A statement that participants can leave the study at will.' This information is crucial to include in the informed document to ensure that participants are aware of their right to withdraw from the study at any time without any negative consequences. Choice B is incorrect because participants should not be assigned to experimental or control groups without their knowledge and consent. Choice C is incorrect because disclosing a list of clients participating in the study violates confidentiality. Choice D is incorrect as the description of the data evaluation framework is important but not as critical as ensuring participants know they can leave the study at will.

Correct Answer: B

Rationale: A weight gain of 0.9 kg (2 lb) in 1 week is an indication of fluid retention, which is concerning in a client with preeclampsia. This can be a sign of worsening condition requiring immediate medical attention. High blood pressure (option A) is expected in preeclampsia, a urine output of 30 mL/hr (option C) is decreased but not as urgent as the weight gain in this scenario, and a respiratory rate of 16/min (option D) is within normal limits.