Nokea
A client is scheduled for a percutaneous kidney biopsy at 1000. The practical nurse reviews the client's vital signs and most current serum laboratory results at 0600. Which of the following client findings is most important to report to the registered nurse?
- A. hemoglobin of 9.8 g/dL (98 g/L)
- B. blood pressure of 180/100 mm Hg
- C. creatinine of 2.0 mg/dL (177 µmol/L)
- D. platelet count of 120,000/mm³ (120 × 10â¹/L)
Correct Answer: B
Rationale: Severe hypertension (180/100 mm Hg) increases bleeding risk during a kidney biopsy, requiring immediate reporting. Other findings are concerning but less urgent.
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The nurse is caring for 4 clients. Which client should the nurse see first?
- A. 2 days post abdominal aortic aneurysm repair with weak pedal pulses and mottled skin on the legs
- B. 2 days post coronary bypass graft surgery with a white blood cell count of 16,000/mm³ (16.0 × 10â¹/L)
- C. Chronic heart failure with peripheral edema and shortness of breath on exertion
- D. Pneumothorax with a chest tube to negative suction and subcutaneous emphysema
Correct Answer: A
Rationale: Weak pulses and mottled skin suggest vascular compromise, a life-threatening complication requiring immediate attention. The other conditions are less urgent.
An adult who had a mastectomy yesterday says to the nurse, 'I guess I'm not a real woman anymore. How could my husband possibly love me now?' What is the best response for the nurse to make?
- A. You don't feel like a woman now?'
- B. Has your husband said anything to you?'
- C. Of course your husband will love you.'
- D. True love is not dependent on breasts.'
Correct Answer: A
Rationale: Reflecting the client's feelings validates her emotional distress, fostering therapeutic communication post-mastectomy. Other responses dismiss or redirect her concerns.
A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client's temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is
- A. Maintain fluid and electrolyte balance
- B. Control nausea
- C. Manage pain
- D. Prevent urinary tract infection
Correct Answer: C
Rationale: Manage pain. The immediate goal of therapy is to alleviate the client's pain, which can be quite severe with kidney stones.
A client with type 1 diabetes has a prescription for 20 units of NPH insulin daily at 7:30 AM and regular insulin before meals, based on a sliding scale. At 7:00 AM, the client's blood glucose level is 220 mg/dL (12.2 mmol/L), and the client's breakfast tray has arrived. What action should the nurse take?
- A. Administer 20 units of NPH insulin now and then 6 units of regular insulin after the morning meal
- B. Administer 26 units of insulin: 20 units of NPH insulin and 6 units of regular insulin in 2 separate injections
- C. Administer 26 units of insulin: 20 units of NPH mixed with 6 units of regular insulin in the same syringe, drawing up the NPH into the syringe first
- D. Administer 26 units of insulin: 20 units of NPH mixed with 6 units of regular insulin in the same syringe, drawing up the regular insulin first
Correct Answer: D
Rationale: Regular insulin is drawn up first to prevent NPH contamination, and both can be mixed in one syringe for a blood glucose of 220 mg/dL, assuming a sliding scale of 6 units. Administering after the meal or using separate injections is incorrect.
A client with a embolus has an order for a continuous infusion of heparin. The doctor has ordered 1,200 units per hour. If the solution contains 1,250 units in $250 \mathrm{~mL}$, the nurse should administer how many $\mathrm{mL}$ per hour?
- A. 12
- B. 24
- C. 36
- D. 48
Correct Answer: B
Rationale: Calculation: (1,200 units/hour ÷ 1,250 units) × 250 mL = 24 mL/hour. This ensures the correct heparin dose is delivered.