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A college student comes to the college health services with complaints of a severe headache, nausea, and photophobia. The physician orders a complete blood count (CBC) and a lumbar puncture (LP). Which of the following lab results would the nurse expect if a diagnosis of bacterial meningitis were made?
- A. Cerebrospinal fluid (CSF) cloudy, Hgb 13 g/dL, Hct 38%, WBC 18,000/mm³.
- B. CSF with RBCs present, Hgb 10 g/dL, Hct 37%, WBC 8,000/mm³.
- C. CSF cloudy, Hgb 12 g/dL, Hct 37%, WBC 7,000/mm³.
- D. CSF clear, Hgb 15 g/dL, Hct 40%, WBC 11,000/mm³.
Correct Answer: A
Rationale: CSF normally clear, colorless; normal WBC 5,000-10,000 per cubic millimeter, normal Hgb (male 13.5-17.5 g/dL, female 12-16 g/dL), normal Hct (male 41-53%, female 36-46%)
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The nurse is caring for a client who has been placed on a hypothermia blanket. What should the nurse include in the care plan?
- A. Take frequent vital signs and perform frequent skin assessments
- B. Leave the hypothermia blanket on until the client's temperature reaches 98.6°F
- C. Place the client directly on the blanket
- D. Apply iced alcohol sponges to the part of the client's trunk not in contact with the blanket
Correct Answer: A
Rationale: Frequent vital signs monitor for hypothermia or cardiovascular instability, and skin assessments prevent pressure injuries or cold burns. Direct blanket contact, prolonged use, or alcohol sponges risk skin damage or ineffective cooling.
The nurse is assigned to a client who has heart failure. During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?
- A. Take the client's vital signs
- B. Place the client in a sitting position with legs dangling
- C. Contact the health care provider
- D. Administer the PRN antianxiety agent
Correct Answer: B
Rationale: Place the client in a sitting position with legs dangling. This reduces venous return, alleviating pulmonary edema symptoms.
A client is to begin taking Fosamax. The nurse must emphasize which of these instructions to the client when taking this medication? 'Take Fosamax
- A. on an empty stomach.'
- B. after meals.'
- C. with calcium.'
- D. with milk 2 hours after meals.'
Correct Answer: A
Rationale: Fosamax should be taken first thing in the morning with 6-8 ounces of plain water at least 30 minutes before other medication or food. Food and fluids (other than water) greatly decrease the absorption of Fosamax. The client must be instructed to remain in the upright position for 30 minutes following the dose to facilitate passage into the stomach and minimize irritation of the esophagus.
The nurse is caring for a client with a history of atrial fibrillation who is receiving amiodarone (Cordarone) 200 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue
- B. Dry cough and shortness of breath
- C. Occasional palpitations
- D. Mild nausea
Correct Answer: B
Rationale: Dry cough and shortness of breath suggest pulmonary toxicity, a serious amiodarone side effect. Options A, C, and D are less urgent: fatigue and nausea are common, and palpitations are expected in atrial fibrillation.
A postoperative appendectomy client who is complaining of incisional pain. A diabetic client who had a cardiac catheterization in the early AM. A postoperative cholecystectomy client who is complaining of incisional pain. A client with congestive heart failure who underwent diuresis in the hospital.
The nurse is planning discharge for a group of clients. It is MOST important to refer which of the following clients for home care?
- A. A postoperative appendectomy client who is complaining of incisional pain.
- B. A diabetic client who had a cardiac catheterization in the early AM.
- C. A postoperative cholecystectomy client who is complaining of incisional pain.
- D. A client with congestive heart failure who underwent diuresis in the hospital.
Correct Answer: D
Rationale: Strategy: Determine the least stable client. Remember the ABCs. (1) expected outcome, treat with analgesics (2) instruct no bending, straining, or lifting heavy objects for 24 hours, observe for bleeding, swelling, new bruising at puncture site (3) expected outcome, treat with analgesics (4) correct-assess for decreased circulating volume, hypotension, tachycardia, monitor for signs and symptoms of hypokalemia