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A nurse is caring for a client with an indwelling urinary catheter. Which intervention is most important to include in the client's plan of care?
- A. Ensure the catheter is below the level of the bladder at all times.
- B. Change the catheter bag every 48 hours.
- C. Cleanse the perineal area daily.
- D. Perform catheter care daily.
Correct Answer: A
Rationale: The correct answer is to ensure the catheter is always below the level of the bladder. Placing the catheter tubing above the level of the bladder can lead to backflow of urine, causing urinary tract infections. Changing the catheter bag every 48 hours is important but not as crucial as maintaining proper catheter positioning. Cleaning the perineal area daily and performing catheter care are essential tasks but do not directly address the prevention of complications associated with catheter placement.
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A client with chronic kidney disease (CKD) is scheduled for a renal biopsy. Which laboratory value is most concerning?
- A. Serum potassium of 5.5 mEq/L
- B. Serum creatinine of 1.5 mg/dl
- C. Serum creatinine of 2.5 mg/dl
- D. White blood cell count of 8,000/mm3
Correct Answer: C
Rationale: A serum creatinine level of 2.5 mg/dl is the most concerning laboratory value in a client with chronic kidney disease scheduled for a renal biopsy. An elevated serum creatinine level indicates impaired kidney function, which is critical information before performing a renal biopsy. Option A (Serum potassium of 5.5 mEq/L) may be concerning for hyperkalemia but is not directly related to the renal biopsy procedure. Option B (Serum creatinine of 1.5 mg/dl) is within normal limits, suggesting relatively normal kidney function. Option D (White blood cell count of 8,000/mm3) is within the normal range and not directly related to the renal biopsy procedure or CKD management.
The nurse is caring for a client with a chest tube in place following a pneumothorax. Which finding requires immediate intervention?
- A. Oxygen saturation of 95%
- B. Crepitus around the insertion site
- C. Subcutaneous emphysema
- D. Drainage of 50 ml per hour
Correct Answer: C
Rationale: Subcutaneous emphysema requires immediate intervention in a client with a chest tube following a pneumothorax as it can indicate a pneumothorax recurrence or air leak. Oxygen saturation of 95% is within the normal range and does not require immediate intervention. Crepitus around the insertion site can be expected post-procedure and may not necessitate immediate action. Drainage of 50 ml per hour is a normal finding and does not raise immediate concerns.
The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer?
- A. Your baby is gaining weight right on schedule
- B. What food does your baby usually eat in a normal day?
- C. The baby is below the normal percentile for weight gain
- D. What was the baby's weight at the last well-baby check-up?
Correct Answer: A
Rationale: The correct answer is A: 'Your baby is gaining weight right on schedule.' Tripling of birth weight by 6 months is a normal growth pattern in infants, indicating appropriate weight gain and development. Choice B is unrelated to the question as it focuses on the baby's diet rather than addressing the weight gain concern. Choice C is incorrect as tripling the birth weight is considered a healthy growth pattern, not below normal percentile. Choice D is irrelevant to the mother's question about the adequacy of weight gain.
A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which clinical finding is most concerning?
- A. Serum glucose of 500 mg/dl
- B. Blood pressure of 140/90 mmHg
- C. Serum osmolarity of 320 mOsm/kg
- D. Serum pH of 7.30
Correct Answer: C
Rationale: A serum osmolarity of 320 mOsm/kg is the most concerning finding in a client with hyperglycemic hyperosmolar syndrome (HHS). This level of osmolarity indicates severe dehydration and hyperosmolarity, putting the client at risk of complications like organ failure. Immediate intervention is crucial to address the dehydration and restore fluid balance. The other options, while important in the overall assessment of a client with HHS, do not directly indicate the severity of dehydration and hyperosmolarity seen with a high serum osmolarity level.
A client with cirrhosis is admitted with jaundice and ascites. Which laboratory value requires immediate intervention?
- A. Serum albumin of 3.0 g/dL
- B. Serum bilirubin of 3.0 mg/dL
- C. Serum ammonia level of 80 mcg/dL
- D. Serum sodium level of 135 mEq/L
Correct Answer: C
Rationale: A serum ammonia level of 80 mcg/dL is most concerning in a client with cirrhosis as it may indicate hepatic encephalopathy, requiring immediate intervention. High serum ammonia levels can lead to altered mental status, confusion, and even coma. Serum albumin (choice A) is often decreased in cirrhosis but does not require immediate intervention. Serum bilirubin (choice B) elevation is expected in cirrhosis and may not require immediate intervention unless very high. Serum sodium (choice D) within the given range is generally acceptable and does not require immediate intervention.