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A client with a postoperative wound that eviscerated yesterday has an elevated temperature. What is the most important intervention for the nurse to implement?
- A. Initiate contact isolation.
- B. Obtain a wound swab for culture and sensitivity.
- C. Assess temperature every 4 hours.
- D. Use alcohol-based solutions for hand hygiene.
Correct Answer: B
Rationale: Obtaining a wound swab for culture and sensitivity is the most important intervention in this situation. It helps identify the presence of infection in the postoperative wound that could be causing the elevated temperature. By obtaining a wound swab, healthcare providers can determine the appropriate treatment needed to address any infection. Initiating contact isolation (Choice A) may be necessary in certain situations but is not the priority in this case. Assessing temperature (Choice C) is important but does not directly address the underlying cause of the elevated temperature. Using alcohol-based solutions for hand hygiene (Choice D) is a standard practice for infection control but is not the most crucial intervention in this scenario.
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A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amounts of liquid stool. Which action should the nurse implement?
- A. Digitally check the client for a fecal impaction
- B. Administer a laxative to stimulate bowel movement
- C. Increase fluid intake to soften stool
- D. Perform a digital rectal examination
Correct Answer: A
Rationale: The correct action for the nurse to implement is to digitally check the client for a fecal impaction. In this scenario, the client's presentation of frequent small amounts of liquid stool after a period of no bowel movement suggests a possible impaction. By performing a digital examination, the nurse can assess for the presence of a blockage that may be causing the symptoms. Administering a laxative (Choice B) without assessing for impaction can worsen the situation. Increasing fluid intake (Choice C) is generally beneficial for bowel health but may not address the immediate issue of a potential impaction. Performing a digital rectal examination (Choice D) is similar to Choice A but is more focused on assessing the rectum itself rather than checking for an impaction.
A nurse is teaching a client with type 2 diabetes about the importance of foot care. Which statement by the client indicates a need for further teaching?
- A. I should check my feet every day for cuts or blisters.
- B. I need to moisturize my feet daily, especially between my toes.
- C. I should wear comfortable shoes that fit well.
- D. I should avoid walking barefoot, even indoors.
Correct Answer: B
Rationale: The correct answer is B. Moisturizing between the toes can create a moist environment that fosters fungal infections. Checking the feet daily for cuts or blisters (choice A) is correct in diabetes management to prevent complications. Wearing comfortable shoes that fit well (choice C) and avoiding walking barefoot (choice D) are also essential in preventing foot ulcers and injuries in diabetic patients.
A client with chronic kidney disease (CKD) is admitted with hyperkalemia. Which intervention should the nurse implement first?
- A. Administer intravenous calcium gluconate.
- B. Administer intravenous insulin and glucose.
- C. Administer intravenous sodium bicarbonate.
- D. Administer a loop diuretic as prescribed.
Correct Answer: B
Rationale: The correct answer is to administer intravenous insulin and glucose first. This intervention helps drive potassium back into the cells, lowering serum levels effectively. Administering intravenous calcium gluconate (choice A) is used to stabilize cardiac membranes in severe hyperkalemia but does not address the underlying cause. Administering intravenous sodium bicarbonate (choice C) is used in metabolic acidosis, not hyperkalemia. Administering a loop diuretic (choice D) can help eliminate potassium but is not the first-line treatment for hyperkalemia in CKD.
A client with chronic kidney disease (CKD) is receiving epoetin alfa (Epogen). Which laboratory value should the nurse monitor closely?
- A. Hemoglobin
- B. White blood cell count
- C. Serum potassium
- D. Serum creatinine
Correct Answer: C
Rationale: The correct answer is C: Serum potassium. When a client with chronic kidney disease (CKD) is receiving epoetin alfa (Epogen), monitoring serum potassium levels closely is crucial. Epoetin alfa stimulates red blood cell production, which can lead to an increase in potassium levels. Hyperkalemia is a potential risk in these clients. Monitoring hemoglobin levels (choice A) is important in assessing the effectiveness of epoetin alfa therapy, but it is not the laboratory value that poses an immediate risk related to the medication. White blood cell count (choice B) and serum creatinine (choice D) are not directly affected by epoetin alfa therapy and are not the priority laboratory values to monitor in this case.
A client is admitted with a possible myocardial infarction. Which laboratory test result is most indicative of a myocardial infarction?
- A. Serum creatine kinase (CK)
- B. Serum troponin
- C. Serum myoglobin
- D. C-reactive protein (CRP)
Correct Answer: B
Rationale: Serum troponin is the most specific and sensitive indicator of myocardial infarction. Troponin levels rise within 3-4 hours after myocardial damage, peak at 10-24 hours, and remain elevated for up to 10-14 days. Creatine kinase (CK) and myoglobin can also be elevated in myocardial infarction, but troponin is more specific to cardiac muscle damage. C-reactive protein (CRP) is a marker of inflammation and is not specific for myocardial infarction.