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A client who wears glasses is under the care of a nurse. Which of the following actions should the nurse take?
- A. Store the glasses in a labeled case.
- B. Clean the glasses with hot water
- C. Clean the glasses with a paper towel.
- D. Store the glasses on the bedside table.
Correct Answer: A
Rationale: It is essential for the nurse to store the client's glasses in a labeled case to ensure they are kept safe and protected from damage. Storing them in a case helps prevent scratches, breakage, or misplacement. This practice promotes proper eyewear hygiene and ensures the client has their glasses readily available when needed. Cleaning the glasses with hot water or a paper towel can potentially damage the lenses or frames. Storing the glasses on the bedside table increases the risk of misplacement or damage.
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A client has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests?
- A. Platelet count
- B. Potassium level
- C. Creatinine clearance
- D. Prealbumin
Correct Answer: A
Rationale: Generalized petechiae and ecchymoses can indicate a potential issue with platelet function or count. Therefore, the most relevant laboratory test to evaluate this condition would be a platelet count. Platelet count helps assess the number of platelets in the blood, which are crucial for clotting and preventing bleeding. Monitoring platelet levels can provide important information about a client's bleeding risk and overall hematologic health.
A client is in a seclusion room following violent behavior and continues to display aggressive behavior. What action should the nurse take?
- A. Confront the client about this behavior.
- B. Express sympathy for the client's situation.
- C. Speak assertively to the client.
- D. Stand within 30 cm (1 ft) of the client when speaking with them.
Correct Answer: A
Rationale: When a client in a seclusion room following violent behavior continues to display aggression, it is essential for the nurse to confront the client about this behavior. Confrontation can help set boundaries, address the behavior, and ensure the safety of both the client and the healthcare team. Expressing sympathy (Choice B) may not address the immediate need for behavior management. Speaking assertively (Choice C) can be important but should be coupled with addressing the specific behavior. Standing within close proximity (Choice D) of an aggressive client can escalate the situation and compromise safety, so it is not the appropriate action to take.
During the assessment of a client receiving packed RBCs, which finding indicates fluid overload?
- A. Low back pain.
- B. Dyspnea.
- C. Hypotension.
- D. Thready pulse.
Correct Answer: B
Rationale: Dyspnea is a key finding indicating fluid overload in a client receiving packed RBCs. Fluid overload can lead to pulmonary edema, causing difficulty breathing or shortness of breath (dyspnea). Low back pain is not typically associated with fluid overload but can be more related to musculoskeletal issues. Hypotension and thready pulse are more indicative of hypovolemia (low fluid volume), not fluid overload.
When caring for a client in the advanced stage of amyotrophic lateral sclerosis (ALS), which of the following referrals is the nurse's priority?
- A. Psychologist
- B. Social worker
- C. Occupational therapist
- D. Speech-language pathologist
Correct Answer: D
Rationale: In the advanced stage of ALS, speech and swallowing difficulties become significant. As a result, the priority referral for the nurse would be a speech-language pathologist. This professional can assist in managing communication challenges and provide strategies to address swallowing issues, ensuring the client's safety and quality of life.
A client with vision loss is under the care of a nurse. Which of the following actions should the nurse AVOID?
- A. Keep objects in the client's room in the same place
- B. Ensure there is high-wattage lighting in the client's room
- C. Approach the client from the side
- D. Allow extra time for the client to perform tasks
Correct Answer: C
Rationale: Approaching a client with vision loss from the side can startle them and may lead to accidents or discomfort. It is important to approach them from the front so they are aware of your presence. Keeping objects in the same place aids in familiarity and reduces the risk of falls. High-wattage lighting enhances visibility for the client. Allowing extra time for tasks accommodates the client's potential slower pace and ensures they can perform tasks safely.