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A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment?
- A. Color of sputum
- B. Lung sounds
- C. Saturation level
- D. White blood cell count (WBC)
Correct Answer: D
Rationale: A decreasing WBC count indicates resolving infection, as HAP elevates WBCs. Sputum color is unreliable, lung sounds improve later, and oxygen saturation reflects oxygenation, not infection status.
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A client is admitted for COPD. Which findings would require the nurse's immediate attention?
- A. Nausea and vomiting
- B. Restlessness and confusion
- C. Low-grade fever and cough
- D. Irritating cough and liquefied sputum
Correct Answer: B
Rationale: Restlessness and confusion. Respiratory failure may be signaled by excessive somnolence, restlessness, aggressiveness, confusion, central cyanosis and shortness of breath. When these findings occur, arterial blood gases (ABGs) should be obtained.
The nurse is teaching a client with atrial fibrillation about the use of Coumadin (warfarin) at home. The need to avoid which of these should be emphasized to the client?
- A. Large indoor gatherings
- B. Exposure to sunlight
- C. Active physical exercise
- D. Foods rich in vitamin K
Correct Answer: D
Rationale: Foods rich in vitamin K. Vitamin K acts as an antidote to the pharmacologic action of Coumadin therapy, decreasing Coumadin's effectiveness. Foods high in vitamin K include dark greens, tomatoes, bananas, cheese, and fish.
A client with type 1 diabetes has a prescription for 30 units of insulin glargine at bedtime. Fingerstick blood glucose measurements are prescribed before meals and at bedtime with regular insulin based on a sliding scale. At 9 PM, the client's blood glucose measurement is 180 mg/dL (10.0 mmol/L). What action should the nurse take?
- A. Administer 30 units of glargine; give the client a snack, then administer 2 units of regular insulin
- B. Administer 30 units of glargine and 2 units of regular insulin in 2 different injections
- C. Mix 30 units of glargine with 2 units of regular insulin in the same syringe, drawing up the glargine first
- D. Mix 30 units of glargine with 2 units of regular insulin in the same syringe, drawing up the regular insulin first
Correct Answer: B
Rationale: The sliding scale indicates 2 units of regular insulin for a glucose of 180 mg/dL. Glargine, a long-acting insulin, should be given as prescribed (30 units). Glargine cannot be mixed with regular insulin in the same syringe due to differing pH levels, so separate injections are required.
An older adult is diagnosed with open-angle glaucoma. Which comment by the client indicates understanding of the management of the condition?
- A. I will take the eye drops every day.'
- B. I hope the medicine works and I am cured soon.'
- C. My wife is worried that I may give her glaucoma.'
- D. How long will it be before I need surgery?'
Correct Answer: A
Rationale: Daily eye drops control intraocular pressure in open-angle glaucoma, a chronic condition, indicating understanding, unlike expecting a cure, contagiousness, or immediate surgery.
The nurse is planning care for a group of senior citizens. The nurse should plan activities that promote achievement of which developmental task?
- A. Identity
- B. Intimacy
- C. Generativity
- D. Ego integrity
Correct Answer: D
Rationale: Ego integrity, accepting one's life as meaningful, is the developmental task for seniors per Erikson's theory. Identity, intimacy, and generativity apply to younger stages.