Nokea
A client with a history of seizures is prescribed phenytoin (Dilantin). Which laboratory value should the nurse monitor?
- A. Liver function tests
- B. Renal function tests
- C. Complete blood count
- D. Electrolytes
Correct Answer: A
Rationale: Phenytoin can cause hepatotoxicity, so liver function tests should be monitored regularly to detect potential liver damage early.
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The nurse has finished suctioning the tracheostomy of a client. Which parameter should the nurse monitor to determine the effectiveness of the procedure?
- A. Breath sounds
- B. Capillary refill
- C. Respiratory rate
- D. Oxygen saturation level
Correct Answer: A
Rationale: After suctioning a client either with or without an artificial airway, the breath sounds are auscultated to determine the extent to which the airways have been cleared of respiratory secretions. The other assessment items are not as precise as breath sounds for this purpose.
The mother of a neonate delivered at 36 weeks' gestation asks why the neonate is being treated for sepsis when no infection is present. Which of the following responses by the nurse is most appropriate?
- A. The neonate may have an infection that we haven't identified yet.'
- B. Premature neonates are more susceptible to infections.'
- C. This is a precautionary measure because the neonate is premature.'
- D. Antibiotics are given to all neonates born before 37 weeks.'
Correct Answer: C
Rationale: Treating a 36-week neonate for sepsis is often precautionary due to their increased risk of infection, even without confirmed infection, to prevent complications.
A client is receiving a transfusion of packed red blood cells. Which of the following actions should the nurse implement to safely administer the blood?
- A. Keep the blood refrigerated on the nursing unit until ready to administer.
- B. Stay with the client during the first 15 minutes to detect signs or symptoms of a reaction.
- C. Do not infuse blood that has been hanging for more than 6 hours.
- D. Administer the blood quickly to prevent wasting it if the client develops a fever.
Correct Answer: B
Rationale: Staying with the client for the first 15 minutes is critical to monitor for acute transfusion reactions, which are most likely to occur early.
Select the complication of a blood transfusion that is accurately paired with its preventive measure.
- A. Hemolysis: Typing and cross matching the blood and checking for ABO compatibility prior to administration
- B. Hemolysis: Insuring that the client does not have a prior history of hemolysis in the past
- C. Febrile reactions: Insuring that the client does not have a prior history of hemolysis in the past
- D. Febrile reactions: Typing and cross matching the blood and checking for ABO compatibility prior to administration
Correct Answer: A
Rationale: Hemolysis is prevented by ensuring ABO compatibility and proper typing and cross-matching to avoid immune reactions.
A client with pneumonia is receiving oxygen at 2 L/min via nasal cannula. The nurse notes a respiratory rate of 30 breaths/min and oxygen saturation of 88%. What should the nurse do first?
- A. Increase the oxygen to 4 L/min
- B. Notify the physician
- C. Encourage deep breathing exercises
- D. Reposition the client to semi-Fowler's
Correct Answer: B
Rationale: An oxygen saturation of 88% and tachypnea indicate worsening hypoxia, requiring immediate physician notification for further orders. Increasing oxygen or repositioning may help but requires a prescription.