Nokea
A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client?
- A. Capillary refill less than 3 seconds
- B. Pale mucous membranes
- C. Respirations 20 breaths per minute
- D. Complaints of fatigue when ambulating
Correct Answer: A
Rationale: Capillary refill less than 3 seconds. Since the hemoglobin and hematocrit are normal for an adult female, additional assessments should be normal. This capillary refill time is normal.
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Laboratory Reference Ranges
Glucose – Fasting
70–110 mg/dL
(3.9–6.1 mmol/L)
A client with type 1 diabetes is prescribed NPH insulin before breakfast and dinner. Although the client reports feeling well, the 6 AM fasting blood glucose is 60 mg/dL. Which action should the nurse recommend to the client?
- A. Collect urine sample to check for urine ketones
- B. Consume a snack of milk and cereal at bedtime
- C. Increase carbohydrate intake at each meal
- D. Take only the prebreakfast dose of NPH
Correct Answer: B
Rationale: A fasting blood glucose of 60 mg/dL indicates hypoglycemia risk with NPH insulin, which peaks overnight. A bedtime snack prevents nocturnal hypoglycemia. Ketones are checked for hyperglycemia, increased carbohydrates may cause hyperglycemia, and skipping doses disrupts control.
The nurse is collecting data from a client who delivered a full-term newborn vaginally 12 hours ago after prolonged labor. Which of the following findings would be essential to follow up?
- A. foul-smelling lochia
- B. external hemorrhoids
- C. temperature of 100 F (37.8 C)
- D. discomfort during fundal massage
Correct Answer: A
Rationale: Foul-smelling lochia suggests possible endometritis or infection, requiring immediate follow-up. External hemorrhoids and mild temperature elevation are common postpartum findings, and discomfort during fundal massage is expected unless accompanied by other concerning signs.
The health care provider has told a client to take over-the-counter supplemental calcium carbonate 1000 mg/day for treatment of osteoporosis. Which instruction should the clinic nurse reinforce with the client?
- A. Monthly calcium levels will need to be drawn
- B. Stop vitamin D supplements when taking calcium
- C. Take calcium at bedtime
- D. Take calcium in divided doses with food
Correct Answer: D
Rationale: Taking calcium carbonate in divided doses with food enhances absorption and reduces GI upset. Monthly calcium levels are unnecessary, vitamin D should continue, and bedtime dosing is less effective.
A client is in suspected shock state from major trauma. Which of the following parameters indicate the adequacy of peripheral perfusion? Select all that apply.
- A. Apical pulse
- B. Capillary refill time
- C. Lung sounds
- D. Pupillary response
- E. Skin color and temperature
Correct Answer: B,E
Rationale: Capillary refill time and skin color/temperature directly assess peripheral perfusion in shock. Apical pulse , lung sounds , and pupillary response evaluate other aspects.
An adult who had a laryngectomy is ready for discharge. What question is it essential for the nurse to ask the client before discharge?
- A. How many people live in your household?
- B. Does your home have working smoke detectors?
- C. Do you cook with gas or electricity?
- D. When is your doctor's appointment?
Correct Answer: B
Rationale: Smoke detectors are critical post-laryngectomy, as impaired speech and potential airway issues increase fire safety risks, making this a priority discharge question.