Nokea
A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to note
- A. High protein
- B. Clear color
- C. Elevated red blood cell count
- D. Increased glucose
Correct Answer: A
Rationale: High protein. A positive CSF for meningitis would include presence of protein, a positive blood culture, decreased glucose, cloudy color with an increased opening pressure, and an elevated white blood cell count.
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Two days after admission, a client's sputum culture is reported as positive for tuberculosis.
While awaiting orders from the physician, the nurse should
- A. initiate measures to transfer the client to a tuberculosis unit.
- B. institute measures to initiate airborne precautions.
- C. arrange for all of the client's personal effects to be decontaminated.
- D. notify the client's family that they have been exposed to a contagious disease.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) this action is unnecessary at this time, and if indicated, the physician will write appropriate transfer orders (2) correct-clients with tuberculosis are placed on airborne precautions in the hospital, and the nurse should begin preparations for this immediately (3) personal effects do not have to be decontaminated (4) it is the physician's job to tell the family when indicated
A 32-year-old multipara is seen in the prenatal clinic. The nurse notes she is in her fifth month of pregnancy and has a weight gain of 14 pounds. The history indicates that prenatally the client was of average height and weight.
The nurse should advise the client that
- A. she has gained too much weight and her diet should be reevaluated.
- B. she has not gained enough weight and her diet should be reevaluated.
- C. her weight gain is appropriate and she should continue on her present diet.
- D. her weight gain indicates that she may have difficulties later in pregnancy.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) excessive weight gain is >6.6 lb (3 kg)/month (2) inadequate weight gain is <2.2 lb (1 kg)/month (3) correct-weight gain 2-5 lb (2.5 kg) first trimester, 0.66-1.1 lb (0.5 kg) weekly in second and third trimester (4) not substantiated by information presented in question
A client scheduled for a Nissen repair for a hiatal hernia is being instructed preoperatively to use the incentive spirometer. The nurse determines that the client has understood the teaching when the client states:
- A. These exercises will help to decrease my pain.
- B. I should use this device once a day.
- C. If I use this device, it will help in preventing pneumonia.
- D. I should do these breathing techniques while lying down flat in bed.
Correct Answer: C
Rationale: Incentive spirometry's purpose is to prevent or treat atelectasis, which can lead to pneumonia. Answer A is a false statement, so it is incorrect. Answer B is incorrect because the timing is not as often as it should be. Answer D is wrong because it is best done sitting upright.
When obtaining a specimen from a client for sputum culture and sensitivity (C and S), the nurse knows that which of the following instructions is BEST?
- A. After pursed-lip breathing, cough into a container.
- B. Upon awakening, cough deeply and expectorate into a container.
- C. Save all sputum for three days in a covered container.
- D. After respiratory treatment, expectorate into a container.
Correct Answer: B
Rationale: specimens should be obtained in the early morning because secretions develop during the night
A client has an order for D5NS 1,000 mL to infuse over 8 hours. The IV set delivers 10 drops per mL. The nurse should maintain the infusion rate at:
- A. 10 drops per minute
- B. 15 drops per minute
- C. 21 drops per minute
- D. 32 drops per minute
Correct Answer: C
Rationale: Calculate: 1,000 mL / 8 hours = 125 mL/hour. 125 mL/hour × 10 drops/mL ÷ 60 minutes = 20.83 drops/minute, rounded to 21 drops/minute.