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A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the health care provider?
- A. Joint pain.
- B. Hematuria.
- C. Low grade fever.
- D. Muscle atrophy.
Correct Answer: B
Rationale: Hematuria indicates potential kidney involvement, a serious complication of SLE that can lead to renal failure. Prompt reporting is critical for timely intervention to prevent end-stage renal disease.
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Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?
- A. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE.
- B. Report the COVID-19 result to the local health department according to CDC guidelines.
- C. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.
- D. Explain to the client to inform others that they may have been potentially exposed in the last 14 days.
Correct Answer: A
Rationale: Isolating the client immediately prevents potential COVID-19 transmission, given the suggestive symptoms, and is the priority action before reporting, educating, or contact tracing.
While caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the health care provider, the nurse should evaluate which laboratory value?
- A. Platelet count.
- B. Serum albumin.
- C. Neutrophil count.
- D. Blood pH level.
Correct Answer: C
Rationale: Neutrophil count is a measure of the body's immune response to infection. Neutrophils are the most abundant type of white blood cells and are the first line of defense against bacterial infections. A high neutrophil count can indicate an acute infection, such as that suggested by purulent drainage from burn wounds.
During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?
- A. Corticosteroid cream was applied to eczema.
- B. A grandson and his new dog recently visited.
- C. An old friend with eczema came for a visit.
- D. Recently received an influenza immunization.
Correct Answer: B
Rationale: Exposure to a new dog may introduce allergens like dander, triggering an eczema flare-up, making this information critical for identifying the cause of the exacerbation.
A client with metastatic cancer reports a pain level of 10 on a pain scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Administer analgesics on a fixed and continuous schedule.
- B. Frequently evaluate the client's pain.
- C. Replace transdermal analgesic patches every 72 hours.
- D. Monitor client for break-through pain.
Correct Answer: A
Rationale: A fixed and continuous analgesic schedule ensures consistent pain relief for chronic severe cancer pain, preventing fluctuations and addressing inadequate response to the initial dose.
A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?
- A. Begin a weight loss program.
- B. Drink 1 to 2 glasses of wine at bedtime.
- C. Take sedatives prior to sleep.
- D. Sleep with the head of the bed flat.
Correct Answer: A
Rationale: Weight loss can reduce fat deposits around the neck and throat, improving airflow and decreasing the severity of OSA, making it an effective alternative or complementary strategy to CPAP.