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A client is scheduled to have a blood test for cholesterol and triglycerides the next day. The nurse would tell the client
- A. Be sure and eat a fat-free diet until the test.'
- B. Do not eat or drink anything but water for 12 hours before the blood test.'
- C. Have the blood drawn within 2 hours of eating breakfast.'
- D. Stay at the laboratory so 2 blood samples can be drawn an hour apart.'
Correct Answer: B
Rationale: Do not eat or drink anything but water for 12 hours before the blood test.' Blood lipid levels should be measured on a fasting sample.
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An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first?
- A. Lung sounds
- B. Urine output
- C. Level of alertness
- D. Appetite
Correct Answer: C
Rationale: Level of alertness. Assessing the level of consciousness (alert vs. lethargic vs. unresponsive) will help the provider determine the severity of the acute episode. If the client is alert, responses to questions about complaints can be followed-up quickly.
The nurse is teaching a client with a new diagnosis of glaucoma about timolol (Timoptic) eye drops. Which of the following instructions should the nurse include?
- A. Apply the drops in the morning.
- B. Report any shortness of breath.
- C. Use the drops every 4 hours.
- D. Avoid blinking after administration.
Correct Answer: B
Rationale: Timolol, a beta-blocker, can cause systemic effects like bronchospasm; shortness of breath requires reporting. Options A, C, and D are incorrect.
After abdominal surgery, a client is admitted from the recovery room with intravenous fluid infusing at 100 cc/h. One hour later, the nurse finds the clamp wide open and notes that the client has received 850 cc.
The nurse would be MOST concerned by which of the following?
- A. A CVP reading of 12 and bradycardia.
- B. Tachycardia and hypotension.
- C. Dyspnea and oliguria.
- D. Rales and tachycardia.
Correct Answer: D
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) CVP is normal, and bradycardia is incorrect (2) does not contain information relevant to fluid overload (3) does not contain information relevant to fluid overload (4) correct-indicate cardiovascular fluid overload
The physician's orders include warm compresses to the left leg three times a day for treatment of an open wound. Which action is appropriate when carrying out these orders?
- A. Use medical aseptic technique.
- B. Leave the wet compress open to the air.
- C. Place both a dry covering and waterproof material over the compress.
- D. Remove the compress after five minutes.
Correct Answer: C
Rationale: A dry covering and waterproof material over the compress maintain warmth and prevent contamination while keeping the surrounding area dry. Aseptic technique is needed for open wounds, open-air compresses lose heat, and five minutes is too short.
The nurse is aware that the effect of antihypertensive drug therapy may be affected by a 75 year-old client's
- A. poor nutritional status
- B. decreased gastrointestinal motility
- C. increased splanchnic blood flow
- D. altered peripheral resistance
Correct Answer: B
Rationale: Decreased gastrointestinal motility, together with shrinkage of the gastric mucosa and changes in hydrochloric acid levels, will decrease absorption of medications and interfere with their actions.