a client begins a regimen of chemotherapy her platelet counts falls to 98000 which action is least likely to increase the risk of hemorrhage

NCLEX-PN

NCLEX-PN Quizlet 2023

1. A client begins a regimen of chemotherapy. Her platelet count falls to 98,000. Which action is least likely to increase the risk of hemorrhage?

A. Test all excreta for occult blood.
B. Use a soft toothbrush or foam cleaner for oral hygiene.
C. Implement reverse isolation.
D. Avoid IM injections.

Correct answer: C

Rationale: The correct answer is to implement reverse isolation. Reverse isolation is a protective measure used to protect patients from infections, not to affect the risk of hemorrhage. Testing all excreta for occult blood (Choice A) is important to monitor for signs of internal bleeding. Using a soft toothbrush or foam cleaner for oral hygiene (Choice B) is recommended to prevent gum bleeding. Avoiding IM injections (Choice D) is crucial to reduce the risk of bleeding in a client with a low platelet count. Therefore, among the given options, implementing reverse isolation is the least likely to increase the risk of hemorrhage.

2. The PN is caring for a client with diabetes insipidus. The nurse can expect the lab work to show:

A. elevated urine osmolarity and elevated serum osmolarity.
B. decreased urine osmolarity and decreased serum osmolarity.
C. elevated urine osmolarity and decreased serum osmolarity.
D. decreased urine osmolarity and elevated serum osmolarity.

Correct answer: D

Rationale: In diabetes insipidus, the pituitary releases too much antidiuretic hormone (ADH), causing the client to produce a large amount of dilute urine (decreased osmolarity) and leading to dehydration (elevated serum osmolarity). Therefore, the correct answer is decreased urine osmolarity and elevated serum osmolarity. Choice C, elevated urine osmolarity and decreased serum osmolarity, is incorrect for diabetes insipidus, as it is more characteristic of syndrome of inappropriate ADH (SIADH). Choices A and B, elevated urine osmolarity and elevated serum osmolarity, and decreased urine osmolarity and decreased serum osmolarity, respectively, are generally not seen in diabetes insipidus, as urine and serum osmolarity typically move in opposite directions in this condition.

3. What advice should be given to a client with stress incontinence?

A. to consider trying Kegel exercises
B. to undergo surgery immediately
C. to avoid all forms of treatment
D. to ignore the issue as it is not serious

Correct answer: A

Rationale: For stress incontinence, advising the client to consider trying Kegel exercises is appropriate. Kegel exercises involve tightening and releasing the pelvic floor muscles, which can improve stress incontinence by strengthening the muscles that control urination. Choice B suggesting immediate surgery is incorrect as surgery is usually considered after conservative treatments like Kegel exercises have been tried. Choice C advising to avoid all forms of treatment is dangerous and neglectful. Choice D recommending to ignore the issue is inappropriate as it can impact the client's quality of life and may worsen over time without intervention.

4. Which is an example of a sentinel event?

A. The terminally ill client is referred to hospice and dies 3 months later.
B. A client receives an unordered mammogram which reveals a small cyst.
C. A client with a laceration to the knee requiring 4 sutures falls when getting up unassisted after being instructed to remain in bed.
D. A client scheduled for knee replacement surgery had an above-the-knee amputation performed.

Correct answer: D

Rationale: Yes! A sentinel event is an unexpected occurrence causing death or serious injury. In this case, a client who was scheduled for knee replacement surgery but had an above-the-knee amputation performed instead represents a sentinel event as it resulted in serious harm that was not intended. The other choices do not meet the criteria for a sentinel event. Choice A describes a natural progression for a terminally ill client, choice B shows an incidental finding from a test, and choice C involves a preventable fall leading to an injury but not a sentinel event.

5. A mother of a newborn notices a nurse placing liquid in her baby's eyes. Which of the following is an inaccurate statement about the need for eyedrops following birth?

A. Eyedrops following birth help reduce the risk of eye infection.
B. Eyedrops are required by law.
C. Eyedrops will keep the eye moist.
D. Eyedrops are required by law every 6 hours following birth.

Correct answer: D

Rationale: The correct answer is 'Eyedrops are required by law every 6 hours following birth.' This statement is inaccurate because while laws do require the placement of eyedrops, physicians indicate a specific timeframe for their administration. Choice A is correct because eyedrops following birth do help reduce the risk of eye infection by preventing ophthalmia neonatorum. Choice B is incorrect as it implies that eyedrops are mandated solely by law, without considering medical reasons. Choice C is accurate as eyedrops do help keep the eye moist, preventing dryness and discomfort.