Nokea
The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value requires immediate intervention?
- A. Serum potassium of 5.5 mEq/L
- B. Serum creatinine of 2.5 mg/dL
- C. Hemoglobin of 10 g/dL
- D. White blood cell count of 10,000/mm³
Correct Answer: A
Rationale: A serum potassium level of 5.5 mEq/L is most concerning in a client receiving erythropoietin therapy as it indicates hyperkalemia, requiring immediate intervention. High potassium levels can lead to severe cardiac arrhythmias and must be addressed promptly. The other laboratory values, though abnormal, do not present immediate life-threatening risks as hyperkalemia does.
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A client with a history of rheumatoid arthritis is prescribed methotrexate. Which laboratory value should the nurse monitor closely?
- A. Liver function tests
- B. Complete blood count
- C. Serum creatinine
- D. Prothrombin time
Correct Answer: C
Rationale: Serum creatinine should be closely monitored in a client receiving methotrexate, as the medication can cause nephrotoxicity. Monitoring serum creatinine levels helps assess kidney function and detect potential nephrotoxic effects of methotrexate. Liver function tests (Choice A) are important to monitor for hepatotoxicity caused by methotrexate. While methotrexate can cause bone marrow suppression, leading to anemia, leukopenia, and thrombocytopenia, monitoring a complete blood count (Choice B) is essential but not the priority in this case. Prothrombin time (Choice D) is not typically affected by methotrexate therapy and is not the primary laboratory value to monitor in this situation.
A client with chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which assessment finding requires immediate intervention?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 24 breaths per minute
- C. Use of accessory muscles
- D. Inspiratory crackles
Correct Answer: C
Rationale: The correct answer is C. The use of accessory muscles indicates increased work of breathing and can signal respiratory failure in a client with COPD. This finding requires immediate intervention to prevent further respiratory compromise. Oxygen saturation of 90% indicates some oxygenation impairment but may not necessitate immediate intervention. A respiratory rate of 24 breaths per minute is slightly elevated but does not indicate immediate respiratory distress. Inspiratory crackles may be present in pneumonia but do not require immediate intervention compared to the increased work of breathing indicated by the use of accessory muscles.
Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3-minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide?
- A. Ask a more experienced nurse to perform that scrub since it is the first time of the day
- B. Validate the nurse is implementing the OR policy for surgical hand scrub
- C. Inform the nurse that hand scrubs should be 3 minutes between cases.
- D. Direct the nurse to continue the surgical hand scrub for a 5-minute duration.
Correct Answer: D
Rationale: The correct answer is to direct the nurse to continue the surgical hand scrub for a 5-minute duration. Surgical hand scrubs should last for 5 to 10 minutes, ensuring thorough cleaning and disinfection. Choice A is incorrect because the nurse should be guided to complete the scrub properly rather than having someone else do it. Choice B is incorrect as it does not address the duration of the hand scrub. Choice C is incorrect as it suggests a 3-minute hand scrub is sufficient, which is inadequate for proper preparation before surgery.
The nurse is caring for a client who is postoperative following a thyroidectomy. Which assessment finding is most concerning?
- A. Slight difficulty swallowing
- B. Hoarse voice
- C. Positive Chvostek's sign
- D. Pain at the incision site
Correct Answer: C
Rationale: A positive Chvostek's sign is the most concerning assessment finding as it suggests hypocalcemia, which is a potential complication following thyroidectomy. Hypocalcemia can lead to serious complications such as tetany and laryngospasm. Immediate intervention is required to prevent further complications. Choices A, B, and D are common post-thyroidectomy findings and are expected during the immediate postoperative period. Slight difficulty swallowing may be due to postoperative swelling, a hoarse voice may be temporary due to intubation trauma, and pain at the incision site is normal after surgery.
A client with chronic heart failure is admitted with shortness of breath and a new onset of confusion. Which intervention should the nurse implement first?
- A. Obtain a neurological assessment.
- B. Administer oxygen therapy.
- C. Monitor the client's urine output.
- D. Obtain an electrocardiogram (ECG).
Correct Answer: A
Rationale: The correct answer is to obtain a neurological assessment. In a client with chronic heart failure presenting with confusion, the priority is to assess neurological status to rule out potential causes such as hypoxia or other complications. Administering oxygen therapy (Choice B) is important but assessing the neurological status takes precedence in this scenario. Monitoring urine output (Choice C) and obtaining an ECG (Choice D) may be necessary but are not the initial priority when a client presents with confusion alongside shortness of breath.