Nokea
A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values?
- A. Blood urea nitrogen
- B. Acid phosphatase
- C. Bilirubin
- D. Sedimentation rate
Correct Answer: C
Rationale: Bilirubin. Hepatitis B causes liver dysfunction, leading to elevated bilirubin levels.
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A client with a fractured hip asks the nurse about activity after discharge. The nurse should explain to the client that she should refrain from which of the following activities?
- A. Crossing her legs at the knee
- B. Sitting in a recliner
- C. Walking up stairs
- D. Carrying objects that weigh more than 10 pounds
Correct Answer: A
Rationale: Crossing legs at the knee can cause hip adduction, risking dislocation in a fractured hip. Other activities are generally safe with proper precautions.
A client with a history of increased intracranial pressure is admitted to the hospital for severe headaches. The client suddenly vomits and states, 'That's weird, I didn't even feel nauseated.' Which action should the nurse take next?
- A. Document the amount of emesis
- B. Lower the head of the bed
- C. Notify the supervising registered nurse
- D. Offer an antinausea medication
Correct Answer: C
Rationale: Sudden vomiting without nausea in increased ICP suggests worsening pressure, requiring immediate RN notification (C). Documentation (A), lowering the bed (B), and antiemetics (D) are secondary.
A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these medications would the nurse anticipate the provider ordering?
- A. Oral Coumadin therapy
- B. Heparin 5000 units subcutaneously B.I.D.
- C. Heparin infusion to maintain the PTT at 1.5-2.5 times the control value
- D. Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value
Correct Answer: C
Rationale: Heparin infusion to maintain the PTT at 1.5-2.5 times the control value. In pregnant women with pulmonary embolism, heparin is preferred over warfarin due to warfarin's teratogenic effects. A continuous heparin infusion is typically used to achieve therapeutic anticoagulation, monitored by maintaining the PTT at 1.5-2.5 times the control value.
The nurse is preparing to irrigate the wound of a 7-year-old client who sustained a laceration while on a playground. Which of the following actions should the nurse take? Select all that apply.
- A. Administer a prescribed analgesic 30 minutes before irrigating the wound
- B. Cleanse the wound from the most contaminated to the least contaminated area
- C. Obtain a 10-mL syringe and a 27-gauge needle
- D. Review the client's vaccination record
- E. Use continuous pressure to flush the wound and repeat until the drainage is clear
Correct Answer: A,D,E
Rationale: Analgesics (A), checking vaccinations (D) for tetanus risk, and continuous flushing (E) are appropriate. Cleaning from contaminated to clean (B) is incorrect, and a 27-gauge needle (C) is too small for irrigation.
A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor?
- A. Step behind client with arms around waist, squat using the quadriceps, and lower client to the floor
- B. Step in front of client, brace knees and feet against the client's, and assist to the floor gently
- C. Step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor
- D. Step 12 inches behind the client, support under axillae, tighten back, and lower client to the floor
Correct Answer: C
Rationale: This technique (C) ensures the nurse maintains balance with feet apart and uses their leg to guide the client safely to the floor, minimizing injury risk to both. Option A risks the nurse losing balance, B places the nurse in an unsafe position, and D involves improper body mechanics.