A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first?
A client who has multiple sclerosis and reports ataxia and vertigo
A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89%
A client who has left-sided paralysis and slurred speech from a prior stroke
A client who has thrombocytopenia and reports a nosebleed
The Correct Answer is D
The nurse should attend to the client who has thrombocytopenia and reports a nosebleed first, as this client has the most urgent problem and is at risk of hemorrhage. Thrombocytopenia is a condition characterized by a low platelet count, which impairs blood clotting and increases bleeding tendencies. The other clients have chronic or stable conditions that require ongoing monitoring and intervention, but are not as urgent as the client with the nosebleed.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should instruct the clients to limit engaging in sport activities that can cause bruising, as radiation therapy can cause thrombocytopenia and increase the risk of bleeding. The nurse should also encourage the clients to increase their fluid intake, eat a balanced diet that includes fresh fruits and vegetables, and protect their skin from sun exposure. The nurse should not advise the clients to limit socializing in large crowds, unless they have a low white blood cell count and are at risk of infection.
Correct Answer is C
Explanation
An incentive spirometer is a device that helps improve lung function by encouraging deep breathing and preventing atelectasis (collapse of alveoli) after surgery or prolonged bed rest. The client should position the mouthpiece firmly in their mouth, inhale deeply and slowly through the mouthpiece until the indicator reaches the desired level, hold their breath for 3 to 5 seconds, and then exhale normally through their nose or mouth.
Exhaling slowly through pursed lips or placing hands on the upper abdomen are techniques that can help with dyspnea (shortness of breath), but are not part of using an incentive spirometer. Positioning the mouthpiece 2.5 cm.
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