Nokea
A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?
- A. Wound culture results that show minimal bacteria
- B. Cloudy, foul-smelling urine output
- C. White blood cell count of 14,000
- D. Temperature of 101°F
Correct Answer: A
Rationale: Minimal bacteria in wound cultures supports the absence of localized infection, aligning with the care plan's goal.
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The nurse is monitoring the labs of a client admitted with viral hepatitis. Which of the following lab findings would the nurse expect for this client? Select all that apply.
- A. decreased ALT levels
- B. increased AST levels
- C. elevated ammonia levels
- D. low serum albumin levels
- E. shortened prothrombin time
Correct Answer: B, C, D
Rationale: Viral hepatitis causes increased AST, elevated ammonia, and low serum albumin due to liver damage. ALT is typically increased, not decreased, and prothrombin time is prolonged.
A nurse is triaging in the emergency room when a client enters complaining of muscle cramps and a feeling of exhaustion after a running competition. Which of the following would the nurse suspect?
- A. Hypernatremia
- B. Hyponatremia
- C. Syndrome of inappropriate antidiuretic hormone (SIADH)
- D. Decreased potassium
Correct Answer: B
Rationale: Hyponatremia is common in runners due to excessive water intake or sodium loss through sweat, leading to muscle cramps and exhaustion. Hypernatremia, SIADH, or low potassium would present differently.
The oncoming nurse receives report on a group of clients. Which client should have priority during the nurse's rounds?
- A. a client who just returned from surgery for an open appendectomy
- B. a client with a blood pressure of 184/86 who has not received the morning dose of lisinopril
- C. a client who is on a 100% non-rebreather mask with an oxygen saturation level of 96%
- D. a client with COPD who is on 2 L of oxygen via nasal cannula with an oxygen saturation level of 90%
Correct Answer: A
Rationale: A client just returning from surgery requires immediate assessment for postoperative complications, making them the priority.
The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should:
- A. Document the finding
- B. Send a specimen to the lab
- C. Strain the urine
- D. Obtain a complete blood count
Correct Answer: B
Rationale: Cloudy dialysate suggests peritonitis, requiring lab analysis.
Which of the following are true statements regarding peripherally inserted central catheter (PICC) lines? Select all that apply.
- A. requires sterile technique during insertion
- B. can be inserted by any LPN or RN
- C. lower risk of infection compared to other central lines
- D. increased risk of pneumothorax
- E. can be inserted at the patient bedside
Correct Answer: A,C,E
Rationale: PICC lines require sterile technique, have a lower infection risk than other central lines, and can be inserted at the bedside. Only specially trained RNs (not any LPN/RN) can insert them, and pneumothorax risk is minimal.