1. To promote evening rest and sleep for clients who are immobilized and in bed, it is most
important for the nurse to provide which care?
a.
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b. Back rubs
c. Daily baths
d. Daytime activities
i. Rationale: daytime activity is particularity important for the immobilized and
bedridden client; it causes these clients to nap less during the day, and provides
relief from tension; enables the client to relax and sleep at night
2. The nurse identifies which lab finding reflects the signs and symptoms of infection?
a. Serum creatinine level of 2.4 mg/dl
b. AST (SGOT) 15 u/l
c. White blood count of 16,000/mm^3
d. White blood count of 4,000/mm^3
i. Rationale: normal range for WBC is 5,000-10,00o/mm^3; elevation indicates
infection
3. A client is admitted to the hospital with a temperature of 101 and a WBC count of 3,000/mm^3.
The nurse should institute which precaution?
a. Contact precautions
b. Airborne precautions
c. Droplet precautions
d. Neutropenic precautions
i. Rationale: client is immunosuppressed; place in a private room, use good hand
washing before touching client and any belongings, limit number of nurses
caring for client; no fresh flowers or potted plants in the client’s room
4. The nurse teaches a client how to maintain an adequate intake of protein. The nurse determines
further teaching is required if the client chooses which foods?
a. Peanut butter on whole wheat bread
b. Rice and red beans
c. Orange juice and white toast
d. Spaghetti and meat sauce
i. Rationale: juice contains little protein, most of it is in the pulp; bread made from
white flour is also limited in its protein content
5. The nurse knows that aspirin, if given in high, prolonged dosages, may precipitate which
physiological change?
a. Urinary frequency
b. Hypoventilation
c. GI bleeding
d. Hemoconcentration
i. Rationale: salicylism results in GI bleeding, blood dyscrasia, and acid-base
disturbances, with fluid and electrolyte imbalances; directly associated with
prolonged high doses of aspirin [Show Less]