Nokea
A female client with ovarian cancer is receiving chemotherapy. Which laboratory result should the nurse report to the healthcare provider immediately?
- A. White blood cell count of 2,000/mm³
- B. Platelet count of 100,000/mm³
- C. Hemoglobin level of 10 g/dL
- D. Serum creatinine level of 1.5 mg/dL
Correct Answer: A
Rationale: A white blood cell count of 2,000/mm³ is critically low and places the client at high risk for infection, requiring immediate intervention. Neutropenia, a low white blood cell count, is a common side effect of chemotherapy. A decreased white blood cell count compromises the immune system's ability to fight infections, making it a priority to address to prevent serious complications. Platelet count of 100,000/mm³ is relatively low but not as urgent as a severely low white blood cell count. Hemoglobin level of 10 g/dL is within the normal range for females and does not require immediate intervention. Serum creatinine level of 1.5 mg/dL is also within the normal range and does not pose an immediate threat to the client's health.
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A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which assessment finding should be reported to the healthcare provider immediately?
- A. Blood pressure of 110/70 mmHg
- B. Heart rate of 80 beats per minute
- C. Fever of 100.4°F
- D. Respiratory rate of 24 breaths per minute
Correct Answer: C
Rationale: The correct answer is C. A fever of 100.4°F is most concerning in a client with ESRD scheduled for hemodialysis as it may indicate an underlying infection, which can lead to serious complications in this population. Elevated body temperature can be a sign of sepsis, which requires immediate attention to prevent further deterioration. Reporting this finding promptly allows for timely intervention. Choices A, B, and D are within normal ranges and do not pose an immediate threat to the client's well-being in the context of preparing for hemodialysis.
A client with a history of chronic kidney disease is scheduled for a CT scan with contrast. Which laboratory value should the nurse review before the procedure?
- A. Serum potassium
- B. Blood urea nitrogen (BUN)
- C. Serum creatinine
- D. Serum glucose
Correct Answer: C
Rationale: Before a CT scan with contrast, the nurse should review the serum creatinine level. This is crucial in assessing kidney function because contrast agents can potentially worsen renal function, leading to contrast-induced nephropathy. Monitoring serum creatinine helps in identifying patients at risk and taking necessary precautions. Serum potassium (Choice A) is important in conditions like hyperkalemia but is not the priority before a contrast CT scan. Blood urea nitrogen (BUN) (Choice B) is another renal function test but is not as specific as serum creatinine for assessing kidney function. Serum glucose (Choice D) is important in monitoring blood sugar levels, especially in diabetic patients, but it is not directly related to the risk of contrast-induced nephropathy in this scenario.
A client who is at 36 weeks gestation is admitted with severe preeclampsia. After a 6-gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse?
- A. Urine output of 20 ml/hour
- B. Blood pressure of 138/88
- C. Respiratory rate of 18 breaths/min
- D. Temperature of 99.8°F
Correct Answer: A
Rationale: A urine output of less than 30 ml/hour indicates that the kidneys are being affected by the high level of magnesium sulfate. This decreased urine output can lead to magnesium toxicity and impaired kidney function. Blood pressure of 138/88 is within normal limits for pregnancy and does not indicate an immediate concern related to magnesium sulfate. A respiratory rate of 18 breaths/min is normal, and a temperature of 99.8°F is slightly elevated but not a priority in the context of severe preeclampsia and magnesium sulfate administration.
A client is being treated with an aminoglycoside antibiotic for a serious gram-negative infection. What nursing action should be included in the plan of care to prevent nephrotoxicity?
- A. Monitor serum creatinine levels daily.
- B. Administer the antibiotic over a longer period of time.
- C. Encourage increased fluid intake.
- D. Restrict dietary protein intake.
Correct Answer: A
Rationale: Monitoring serum creatinine levels daily is the essential nursing action to prevent nephrotoxicity from aminoglycoside antibiotics. Aminoglycosides can cause kidney damage, so monitoring serum creatinine levels helps in detecting early signs of nephrotoxicity. Administering the antibiotic over a longer period of time (choice B) does not directly prevent nephrotoxicity. Encouraging increased fluid intake (choice C) is a general good practice but not specifically aimed at preventing nephrotoxicity. Restricting dietary protein intake (choice D) is not a direct preventive measure against aminoglycoside-induced nephrotoxicity.
A client with chronic liver disease is admitted with ascites and jaundice. Which assessment finding is most concerning?
- A. Enlarged spleen
- B. Increased abdominal girth
- C. Yellowing of the skin
- D. Confusion and altered mental status
Correct Answer: D
Rationale: Confusion and altered mental status are concerning in a client with chronic liver disease, as they may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Enlarged spleen (choice A) can be a common finding in liver disease due to portal hypertension but may not be as acute as hepatic encephalopathy. Increased abdominal girth (choice B) is typically seen in ascites, which is already present in this client. Yellowing of the skin (choice C) is a manifestation of jaundice, also a known symptom in liver disease but not as acute as confusion and altered mental status.