Question

A nurse is caring for an older adult client who has a WBC count of 2,000/mm3 after three rounds of chemotherapy. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Serve cooked fruit with meals.

Rationale :

🍎Cooked fruits reduce the risk of introducing pathogens, which is critical for clients who are immunosuppressed due to chemotherapy.

🍇Raw fruits and vegetables can harbor bacteria or fungi that pose a serious risk when white blood cell (WBC) counts are low, as seen with a WBC count of 2,000/mm³.

🍽️Clients undergoing chemotherapy should follow a neutropenic diet, which includes thoroughly cooked foods to reduce microbial exposure.

🛑Providing raw produce, unpasteurized products, or undercooked meats should be strictly avoided in neutropenic patients to prevent life-threatening infections.

📌Core Message

Neutropenic precautions include avoiding raw foods to prevent infection in clients with severely reduced WBC counts. Cooked fruits are safe and appropriate in this context.

Answer 2

Correct Answers

Apply ice to the scrotum and penis. [ Anticipated ]
Administer an antispasmodic medication. [ Anticipated ]
Place the client in the sitting position while in bed. [ Contraindicated ]
Teach the client how to use a leg bag. [ Anticipated ]

Rationale :

🧊Ice application helps reduce edema and pain after scrotal and perineal surgery, which is a standard post-radical prostatectomy measure.

💊Antispasmodics like oxybutynin may be used to reduce bladder spasms, which are common with indwelling catheters and CBI (continuous bladder irrigation).

🪑Sitting upright increases perineal pressure, which may worsen edema and bleeding in the immediate postoperative period; therefore, it is contraindicated.

🦵Teaching about a leg bag promotes independence and is essential for catheter care as the patient transitions from hospital to home.

📌Core Message

For clients post-radical prostatectomy, reducing swelling, managing bladder spasms, and promoting catheter care are anticipated, while high-pressure positions like sitting upright are contraindicated.

Answer 3

Correct Answers:

WBC count
Platelet count
Bleeding episodes
Oral health

Rationale :

📉An improved WBC count means the client is at lower risk for infection, indicating recovery of immune function.

🧬A rise in platelet count suggests improved bone marrow function, reducing the risk of bleeding.

🩸The absence of bleeding episodes, particularly in the mouth, is a positive sign of mucosal healing and stable clotting.

🦷Better oral health, such as reduced inflammation, reflects the effectiveness of oral care instructions and mucosal recovery.

⚖️Although the client has lost some weight, improvement in labs and clinical symptoms outweighs this factor for this context.

📌Core Message

Improvements in WBC count, platelet count, bleeding episodes, and oral health indicate recovery of immune and clotting functions in a client undergoing chemotherapy.

Answer 4

Correct Answers:

"After a couple of years, I will be able to stop taking the Tacrolimus!"

Rationale :

👉This statement indicates a misunderstanding, as immunosuppressive therapy is lifelong following organ transplantation to prevent rejection.

📆Stopping medications like tacrolimus places the transplanted kidney at high risk for rejection, even years after the surgery.

💊The need for multiple immunosuppressants arises from targeting different pathways in the immune system.

🧪Close monitoring for malignancies is necessary, as long-term immunosuppression increases the risk of cancer.

📌Core Message

Lifelong immunosuppressive therapy, including tacrolimus, is essential after kidney transplantation to prevent rejection, and stopping it is a misconception.

Answer 5

Correct Answers:

0.5

Rationale :

💊125 mcg is equivalent to 0.125 mg, and the available tablet is 0.25 mg, meaning only half a tablet is required.

🧮This is a dose conversion question requiring conversion from micrograms to milligrams (1,000 mcg = 1 mg).

📏Precision is critical with digoxin, a medication with a narrow therapeutic range, to prevent toxicity.

✅Accurate dose calculation ensures client safety and optimal heart failure management.

📌Core Message

Proper unit conversion and precision in dosing are critical when administering narrow therapeutic index drugs like digoxin.

Answer 6

Correct Answers:

125

Rationale :

🧮To determine infusion rate, divide total volume (1,000 mL) by the total hours (8 hr) to get 125 mL/hr.

⏱️This calculation ensures the fluid is evenly administered throughout the prescribed timeframe.

💧0.45% NaCl is a hypotonic solution commonly used for hydration or maintenance fluids.

📊Using the IV pump accurately ensures controlled fluid delivery and prevents volume overload.

📌Core Message

Use basic rate calculation (volume ÷ time) to ensure accurate IV fluid administration and prevent complications.

Answer 7

Correct Answers:

An unconscious adult client who has a sucking chest wound, respirations of 38/min, and capillary refill of <2 seconds

Rationale :

🩺This client is unconscious with a sucking chest wound, which is a sign of a life-threatening open pneumothorax requiring immediate intervention.

💨The high respiratory rate (38/min) and air movement through the wound indicate respiratory compromise, making this client a priority.

🚑Although other clients have urgent conditions, none has immediate airway compromise combined with altered LOC.

👃Immediate interventions like sealing the chest wound can restore ventilation and prevent tension pneumothorax.

📌Core Message

In emergency triage, airway-compromising injuries like sucking chest wounds in unconscious clients demand immediate attention.

Answer 8

Correct Answers:

Assess further for a cause of the decreased circulation

Rationale :

🦵Absent pedal pulses and a swollen leg after trauma suggest possible compartment syndrome or arterial injury.

🔎The priority is to identify the underlying cause of the decreased circulation before further interventions.

🦵Delayed assessment may lead to limb ischemia, tissue necrosis, or even amputation.

🩻Identifying the cause early helps direct interventions like surgical decompression (fasciotomy) or vascular repair.

📌Core Message

Assessing the cause of impaired circulation is essential in trauma to guide limb-saving interventions.

Answer 9

Correct Answers:

Assist with intubation of the patient.

Rationale :

💤The patient is unconscious and at high risk of aspiration, so airway protection via intubation is the top priority.

🫁Gastric lavage and charcoal require a protected airway to prevent aspiration of gastric contents.

🧪Lorazepam overdose leads to CNS depression, compromising the airway reflexes, increasing the urgency of intubation.

🚫Initiating gastric procedures without intubation can result in fatal aspiration events.

📌Core Message

For unconscious overdose patients, airway protection via intubation must come before any gastric decontamination procedures.

Answer 10

Correct Answers:

Attempt to remove the patient's stings.

Rationale :

🐝Removing the stingers reduces venom release, which is the primary emergency action in multiple bee stings.

⏱️The longer stingers remain embedded, the more venom continues to be delivered, increasing risk of reaction.

🧊Ice packs and antihistamines help later, but they don’t stop the ongoing envenomation.

🩺Immediate mechanical removal minimizes allergic reaction severity and systemic spread.

📌Core Message

In bee stings, removing stingers immediately halts further venom delivery, making it the first priority in emergency care.

Options	Anticipated	Nonessential	Contraindicated
Apply ice to the scrotum and penis.
Administer an antispasmodic medication.
Place the client in the sitting position while in bed.
Teach the client how to use a leg bag.

1 :
A nurse is caring for an older adult client who has a WBC count of 2,000/mm3 after three rounds of chemotherapy. Which of the following actions should the nurse take?

2 :
A nurse is caring for a client who has had an open radical prostatectomy.

Correct Answers

3 :
A nurse is caring for a client who has cancer and is undergoing chemotherapy.

Answer Options

4 :
The nurse teaches patients about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions?

6 :
A nurse is preparing to administer 0.45% sodium chloride (NaCl) 1000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

7 :
A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?

8 :
During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?

9 :
Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?

10 :
The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?

1 : A nurse is caring for an older adult client who has a WBC count of 2,000/mm3 after three rounds of chemotherapy. Which of the following actions should the nurse take?

2 : A nurse is caring for a client who has had an open radical prostatectomy.

Correct Answers

3 : A nurse is caring for a client who has cancer and is undergoing chemotherapy.

Answer Options

4 : The nurse teaches patients about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions?

6 : A nurse is preparing to administer 0.45% sodium chloride (NaCl) 1000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

7 : A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?

8 : During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?

9 : Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?

10 : The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?

1 :
A nurse is caring for an older adult client who has a WBC count of 2,000/mm3 after three rounds of chemotherapy. Which of the following actions should the nurse take?

2 :
A nurse is caring for a client who has had an open radical prostatectomy.

3 :
A nurse is caring for a client who has cancer and is undergoing chemotherapy.

4 :
The nurse teaches patients about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions?

6 :
A nurse is preparing to administer 0.45% sodium chloride (NaCl) 1000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

7 :
A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?

8 :
During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?

9 :
Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?

10 :
The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?