Nokea
The clinic nurse is reinforcing instructions to a client who will be wearing a Holter monitor for the next 24 hours. Which instructions are important to review with the client?
- A. How to transmit the readings over the phone
- B. Keep a diary of activities and any symptoms experienced
- C. Refrain from exercising while wearing the monitor
- D. The monitor may be removed only when bathing
Correct Answer: B
Rationale: Keeping a diary of activities and symptoms correlates events with cardiac readings, aiding diagnosis. Transmitting readings is not client responsibility, and Holter monitors are typically worn continuously, including during bathing.
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A client visiting a family planning clinic is suspected of having an STD. The most diagnostic test for all stages of treponema pallidum (syphilis) is the:
- A. Venereal Disease Research Lab (VDRL)
- B. Rapid plasma reagin (RPR)
- C. Florescent treponemal antibody (FTA-Abs)
- D. Thayer-Martin culture (TMC)
Correct Answer: C
Rationale: The FTA-Abs test is the most specific and diagnostic for all stages of syphilis. VDRL and RPR are non-treponemal tests that can have false positives, so A and B are incorrect. Thayer-Martin culture is used for gonorrhea, so D is incorrect.
A culture is taken of a lesion suspected of being herpes. The nurse knows that the specimen:
- A. Should be packed on ice
- B. Should be kept warm
- C. Should be double bagged
- D. Requires no special handling
Correct Answer: A
Rationale: Herpes culture specimens should be packed on ice to preserve the virus for accurate laboratory testing.
The nurse is contributing to a staff education program about assessing the urinary system. Which statement by a nurse would indicate a correct understanding of the program?
- A. The bladder should be nontender and nonpalpable when it is empty
- B. Dark brown urine may indicate that the client has a urinary tract infection
- C. I should be able to palpate both kidneys regardless of the client’s abdominal girth
- D. I will assess for tenderness of the kidneys by performing blunt percussion over the client’s lower abdomen
Correct Answer: A
Rationale: An empty bladder is nontender and nonpalpable, indicating correct understanding. Dark brown urine suggests dehydration or other issues, not UTI; kidneys are not always palpable; and percussion is over the costovertebral angle, not lower abdomen.
The nurse should initiate discharge planning for a client
- A. When the client or family demonstrate readiness to learn self care modalities
- B. When informed that a date for discharge has been determined
- C. Upon admission to a hospital unit or the emergency room
- D. When the client's condition is stabilized on the assigned unit
Correct Answer: C
Rationale: Upon admission to a hospital unit or the emergency room. Early discharge planning ensures continuity of care with shorter hospital stays.
The nurse is evaluating the effectiveness of the medication regimen for a client with chronic kidney disease who is receiving sodium polystyrene sulfonate. It would indicate that the medication regimen has been effective if the client’s most recent laboratory test results indicate
- A. an increase in the serum calcium level
- B. an increase in the serum creatinine level
- C. a decrease in the serum potassium level
- D. a decrease in the serum phosphate level
Correct Answer: C
Rationale: Sodium polystyrene sulfonate treats hyperkalemia in chronic kidney disease by exchanging sodium for potassium in the gut, so a decreased potassium level indicates effectiveness. Calcium levels are not directly affected, and rising creatinine indicates worsening kidney function.