Question

A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching?

Answer 1

Correct Answers:

Aplastic anemia results from decreased bone marrow production of RBCs.

Rationale :

🩸Aplastic anemia is caused by bone marrow suppression, which reduces the production of RBCs, WBCs, and platelets, leading to pancytopenia.

📘Unlike pernicious anemia, which involves vitamin B12 absorption issues, aplastic anemia is not related to nutritional deficiency.

⚖️The primary defect is a failure of the bone marrow stem cells, not destruction of existing cells as seen in hemolytic anemias.

🛡️Clients with aplastic anemia are at risk for infection, bleeding, and fatigue due to reduced cell lines, making early recognition and teaching critical.

📌Core Message

Aplastic anemia occurs due to impaired bone marrow function, leading to reduced production of all blood cells rather than issues with nutrient absorption or cell destruction.

Answer 2

Correct Answers:

Have the client lie flat in bed.

Rationale :

🛏️Following a cardiac catheterization, the client must remain in a supine position to prevent bleeding at the catheter insertion site, especially if the femoral artery was used.

💉Flexing the leg or elevating the head of the bed too high can increase pressure at the puncture site, raising the risk of hematoma or hemorrhage.

📊Keeping the client NPO is unnecessary after the procedure unless there are other contraindications, since dietary restrictions are not part of post-care.

🛡️The priority is to maintain hemostasis and vascular integrity, which is best achieved by lying flat and keeping the affected leg straight.

📌Core Message

After cardiac catheterization, the nurse’s priority is to maintain vascular integrity and prevent bleeding by ensuring the client remains supine with the leg straight.

Answer 3

Correct Answers:

Hip arthroplasty

Rationale :

🦵A hip arthroplasty is a major surgery that leads to prolonged immobility, which increases the risk of venous stasis and clot formation.

🩸The surgical trauma can cause endothelial injury, activating the clotting cascade and further raising the chance of clot development.

📊This condition directly contributes to the risk of deep-vein thrombosis (DVT) in postoperative patients.

🛡️Clients recovering from hip replacement must be closely monitored and managed with preventive measures such as anticoagulants and early mobilization.

📌Core Message

Hip arthroplasty places clients at high risk for deep-vein thrombosis due to immobility and endothelial injury.

Answer 4

Correct Answers:

Airway patency

Rationale :

🌬️After a partial laryngectomy, the highest priority is maintaining a clear airway because swelling or obstruction can rapidly impair breathing.

⚠️This aligns with the principle of ABCs (airway, breathing, circulation), where airway always comes first.

🫁Compromise in airway patency can quickly become life-threatening if not recognized and managed immediately.

🛡️Assessing and ensuring airway patency is therefore the nurse’s first action in the immediate postoperative period.

📌Core Message

The nurse must prioritize airway patency after a partial laryngectomy, since airway obstruction can be rapidly life-threatening.

Answer 5

Correct Answers:

Smoking cessation

Rationale :

🚬Smoking is the primary cause of chronic bronchitis, as it damages the airways and increases mucus production.

📘Stopping smoking directly reduces inflammation and mucus hypersecretion, slowing the progression of the disease.

⚠️It is the most effective prevention strategy because it removes the main risk factor for the disorder.

🛡️Teaching patients to quit smoking is the best health promotion approach to prevent chronic bronchitis.

📌Core Message

Smoking cessation is the most effective prevention for chronic bronchitis because it removes the primary causative factor.

Answer 6

Correct Answers:

Intercostal retractions

Rationale :

🫁Atelectasis with hypoxia increases the client’s work of breathing, leading to intercostal retractions.

📊This occurs as the body generates stronger negative pressure to draw air into collapsed alveoli.

🩺Retractions are an early, visible sign of respiratory distress and hypoxia.

🛡️Recognizing retractions allows for immediate intervention to improve oxygenation.

📌Core Message

Intercostal retractions indicate respiratory distress in clients with atelectasis and hypoxia.

Answer 7

Correct Answers:

The laboratory values are prolonged.

Rationale :

🧪In disseminated intravascular coagulation (DIC), clotting factors are consumed, resulting in prolonged PT, aPTT, and INR.

🩸The body enters a state of excessive clotting and bleeding, exhausting coagulation proteins and platelets.

⚠️This leads to an inability to form stable clots, making the blood take longer to clot.

🛡️Prolonged values are a hallmark of DIC progression and require urgent intervention.

📌Core Message

In DIC, coagulation tests like PT, aPTT, and INR become prolonged due to depletion of clotting factors.

Answer 8

Correct Answers:

Rifampin
Isoniazid
Pyrazinamide

Rationale :

💊Standard treatment for tuberculosis uses a combination of Rifampin, Isoniazid, Pyrazinamide, and Ethambutol.

📘Using multiple drugs prevents the development of drug resistance and ensures effective bacterial eradication.

⚠️These medications target Mycobacterium tuberculosis directly and must be taken for a prolonged period.

🛡️Patient teaching focuses on strict adherence to the multidrug regimen to prevent relapse.

📌Core Message

Tuberculosis therapy requires multidrug regimens such as Rifampin, Isoniazid, and Pyrazinamide to ensure eradication and resistance prevention.

Answer 9

Correct Answers:

Place the client on his left side in Trendelenburg position.

Rationale :

🫀When an air embolism is suspected, the client is placed on the left side in Trendelenburg to trap air in the right atrium.

📊This position prevents the air from traveling into the pulmonary circulation, reducing risk of embolization.

⚠️It allows time for further interventions while minimizing hemodynamic compromise.

🛡️This positioning is the immediate life-saving action for suspected air embolism.

📌Core Message

For air embolism, the client should be placed on the left side in Trendelenburg to trap air and prevent pulmonary embolization.

Answer 10

Correct Answers:

The fourth heart sound (S4)

Rationale :

❤️An extra heart sound heard just before S1 is the S4 heart sound, caused by forceful atrial contraction against a stiff ventricle.

📘It is commonly linked to ventricular stiffness and hypertension.

⚠️Identifying S4 helps detect decreased ventricular compliance in conditions such as hypertensive heart disease.

🛡️Correct documentation of S4 guides cardiac assessment and treatment planning.

📌Core Message

The S4 heart sound occurs before S1 and is associated with ventricular stiffness and hypertension.

1 :
A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching?

2 :
A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?

3 :
A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis?

4 :
A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

5 :
A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder?

6 :
A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expert?

7 :
A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?

8 :
A nurse is teaching a client who has tuberculosis and is to start combination drug therapy. Which of the following medications should the nurse plan to administer? (Select all that apply.)

9 :
A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time?

10 :
A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?

1 : A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching?

2 : A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?

3 : A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis?

4 : A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

5 : A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder?

6 : A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expert?

7 : A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?

8 : A nurse is teaching a client who has tuberculosis and is to start combination drug therapy. Which of the following medications should the nurse plan to administer? (Select all that apply.)

9 : A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time?

10 : A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?

1 :
A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching?

2 :
A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?

3 :
A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis?

4 :
A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

5 :
A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder?

6 :
A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expert?

7 :
A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?

8 :
A nurse is teaching a client who has tuberculosis and is to start combination drug therapy. Which of the following medications should the nurse plan to administer? (Select all that apply.)

9 :
A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time?

10 :
A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?