Nokea
A client has undergone a lumbar puncture for examination of the CSF. Which of the following findings should be considered abnormal?
- A. Total protein $40 \mathrm{mg} / 100 \mathrm{~mL}$
- B. Glucose $60 \mathrm{mg} / 100 \mathrm{~mL}$
- C. Clear, colorless appearance
- D. White blood cells $100 / \mathrm{cu}$. $\mathrm{mm}$
Correct Answer: D
Rationale: Elevated white blood cells (100/cu.mm) in CSF suggest infection or inflammation, an abnormal finding. Normal protein, glucose, and clear appearance are expected.
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The geriatric residents of a long-term care facility are engaged in a reminiscing group. The nurse knows that the primary goal of this type of group activity is to
- A. provide psychosocial educational opportunities for stress and coping.
- B. provide an avenue for physical exercise.
- C. provide an environment for social interaction and companionship.
- D. reorient and provide a reality Test for confused clients.
Correct Answer: C
Rationale: primary goal of a reminiscing group for geriatric clients is to review and share their life experiences with the group members
A client has a total laryngectomy with a permanent tracheostomy.
Which of the following would be necessary for the nurse to consider regarding the client's nutrition?
- A. To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented.
- B. The client will be unable to maintain any PO intake as long as he has a tracheotomy in place.
- C. Nutritional and/or gastric feedings will not be attempted for approximately three weeks to decrease the incidence of aspiration.
- D. Since the client is dependent on the ventilator, nutritional intake will be delayed.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-tube feedings frequently started as the initial nutritional intake; prevents trauma to suture area (2) although the client has permanent tracheotomy, will be able to eat normally after area has healed (3) nutritional intake will begin when bowel sounds return and client can tolerate intake (4) client is not dependent on ventilator
Which of the following findings is consistent with a diagnosis of congestive heart failure?
- A. Jugular vein distention indicates increased fluid volume
- B. Carbon dioxide reading of 30
- C. Hemoglobin of 18
- D. Potassium level of 5.5
Correct Answer: A
Rationale: Jugular vein distention reflects increased fluid volume and right-sided heart failure, a hallmark of congestive heart failure. Other options are not specific to this condition.
A postoperative client has pain medication ordered PRN for discomfort. During the first assessment, the nurse notes that the client has not received pain medication all day. His vital signs are within normal limits, but he is sweating profusely. He smiles at you while speaking and states that he is not hot but is still experiencing some pain and has been since early this morning. What is the most appropriate nursing action?
- A. Administer the largest dose of pain medication allowed because he has been without it all day and then allow him to rest undisturbed.
- B. Administer the minimum dose of medication and reassess his level of pain 30 minutes after administration.
- C. Hold the pain medication because his vital signs are within normal limits and he is smiling and showing no evidence of being in pain.
- D. Encourage the client to continue to do without pain medication so he won't become addicted to the opioid.
Correct Answer: B
Rationale: Administering the minimum dose and reassessing ensures effective pain management while monitoring response, given diaphoresis and reported pain.
A client in the ICU is given procainamide HCl (Pronestyl) slowly IV push.
- A. Which observation would prompt the nurse to withhold the next dose of procainamide?
- B. Presence of premature ventricular contractions.
- C. Occurrence of severe hypotension.
- D. Recurring paroxysmal atrial tachycardia.
- E. A sedimentation rate of 10.
Correct Answer: B
Rationale: Severe hypotension is a serious side effect of procainamide, requiring the dose to be withheld to prevent cardiovascular collapse. PVCs and atrial tachycardia are arrhythmias the drug treats, and a normal sedimentation rate is irrelevant.