Nokea
A 34-year-old man comes to the clinic for the results of a glycosylated hemoglobin assay (HbA1c). Which statement, if made by the client to the nurse, indicates an understanding of this procedure?
- A. This Test is performed by sticking my finger and measuring the results.
- B. This Test needs to be performed in the morning before I eat breakfast.
- C. This Test indicates how well my blood sugar has been controlled the past 6-8 weeks.
- D. I must follow my diet carefully for several days before the Test .
Correct Answer: C
Rationale: when RBCs are being formed, sugar is attached (glycosylated) and remains attached throughout the life of the RBC
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The nurse is caring for a client with a history of spinal cord injury.
- A. Which intervention is most effective for preventing autonomic dysreflexia in a client with a spinal cord injury?
- B. Monitor blood pressure regularly.
- C. Administer analgesics for pain.
- D. Keep the bladder empty.
- E. Encourage a low-fiber diet.
Correct Answer: C
Rationale: Keeping the bladder empty prevents distension, a common trigger for autonomic dysreflexia, a life-threatening hypertensive crisis in spinal cord injury. Blood pressure monitoring detects it, analgesics are irrelevant, and high-fiber diets prevent constipation.
The nurse is caring for a client receiving chemotherapy who is experiencing neutropenia. Which intervention would be most appropriate to recommend for inclusion in the client's plan of care?
- A. Assess the client's temperature every 4 hours due to risk of hypothermia.
- B. Instruct the client to avoid large crowds and people who are sick.
- C. Instruct the client in the use of a soft toothbrush.
- D. Assess the client for hematuria.
Correct Answer: B
Rationale: Neutropenia increases the risk of infection due to low neutrophil counts. Avoiding large crowds and sick individuals minimizes exposure to pathogens, making B the most appropriate intervention. Answer A is incorrect as hypothermia is not a primary concern. Answer C, while relevant for preventing mucosal bleeding, is less critical than infection prevention. Answer D is unrelated to neutropenia.
The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?
- A. Stand on 1 foot
- B. Catch a ball
- C. Skip on alternate feet
- D. Ride a bicycle
Correct Answer: A
Rationale: Stand on 1 foot. Balancing on one foot is expected by age 3, indicating gross motor delay if absent.
A client is admitted with renal calculi and is experiencing severe pain. Meperidine (Demerol) 75 mg IM is given prior to the change of shift.
Which of the following symptoms is MOST important for the nurse to report to the next shift?
- A. Nausea with a small amount of vomitus.
- B. Pain of five on a scale of one to ten.
- C. Change in the location and character of pain.
- D. No known drug allergies.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to renal calculi. (1) often accompanies pain, but is not most important to report to next shift (2) important, but not the highest priority (3) correct-location of the pain depends on location of renal stone; character of pain changes depending on location or movement of stone (4) important, but not the highest priority
A client has a cataract removed from the left eye. Which of the following is an important nursing intervention in the immediate postoperative period?
- A. Position the client on the right side with the head slightly elevated.
- B. Place the client on the left side to protect the eye.
- C. Perform sensory neurological checks every two hours.
- D. Maintain complete bedrest for the first 48 hours.
Correct Answer: A
Rationale: Positioning on the right side with head elevation prevents pressure on the surgical eye, reducing complications. Options B, C, and D are incorrect.