Nokea
A client has fludrocortisone acetate (Florinef) prescribed. What blood tests should the nurse monitor when administering this drug?
- A. Liver function tests
- B. Renal function tests
- C. Serum electrolytes
- D. Complete blood count
Correct Answer: C
Rationale: Fludrocortisone, a mineralocorticoid, affects sodium and potassium balance, requiring monitoring of serum electrolytes to detect imbalances like hypernatremia or hypokalemia.
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A client with newly diagnosed diabetes mellitus.
Which of the following statements, if made by the client to the nurse, would indicate that further teaching is necessary?
- A. I should cut my toenails straight across.
- B. I should not go barefoot.
- C. I should inspect my feet once a week.
- D. I should bathe my feet daily in warm water.
Correct Answer: C
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) prevents ingrown nails (2) prevents possible injury to feet (3) correct-should inspect feet daily for blisters, sores, ingrown nails, and cuts (4) proper care
When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse’s actions during this intervention?
- A. The restraints/seclusion policies set forth by the institution.
- B. The patient’s competence.
- C. The patient’s voluntary/involuntary status.
- D. The patient’s nursing care plan.
Correct Answer: C
Rationale: The need for restraints is based on the patient’s behavior and safety risks, not their voluntary or involuntary admission status. Institutional policies, patient competence, and the care plan guide restraint use to ensure safety and compliance with legal and ethical standards.
A 60-year-old man with a diagnosis of pneumonia.
The nurse should place the patient in a room with which of the following patients?
- A. A 20-year-old in traction for multiple fractures of the left lower leg.
- B. A 35-year-old with recurrent fever of unknown origin.
- C. A 50-year-old recovering alcoholic with cellulitis of the right foot.
- D. An 89-year-old with Alzheimer's disease awaiting nursing home placement.
Correct Answer: C
Rationale: Strategy: Determine the transmission of organisms. (1) patient with fractures are considered 'clean,' don't place with an infectious patient (2) don't know the cause of the fever (3) correct-generalized nonfollicular infection that involves deeper connective tissue, both patients have infections (4) elderly are high risk for developing pneumonia
The nurse is preparing to care for a client who has returned to the surgical nursing unit following a radical neck dissection.
- A. What is the most appropriate nursing action for a client post-radical neck dissection with a tracheostomy?
- B. Suction the tracheostomy every four hours.
- C. Provide tracheostomy care every 12 hours.
- D. Assess the tracheostomy for patency every shift.
- E. Monitor the tracheostomy site for bleeding or swelling.
Correct Answer: D
Rationale: Following a radical neck dissection, monitoring the tracheostomy site for bleeding or swelling is critical due to the risk of hematoma or airway obstruction, which can be life-threatening. Suctioning and care are important but follow a schedule or as needed, and patency assessment is less urgent than monitoring for surgical complications.
A baby boy is delivered after a rapid labor of three hours. What nursing action takes priority in the immediate newborn period?
- A. Suctioning with a bulb syringe
- B. Wrapping the baby in warm blankets
- C. Applying identification bracelets and taking footprints
- D. Assigning an APGAR score
Correct Answer: A
Rationale: Suctioning with a bulb syringe clears airways, ensuring respiratory patency, the priority in the immediate newborn period to prevent aspiration.