Nokea
A healthcare professional is reviewing the laboratory findings of a client who has diabetes mellitus. Which of the following findings indicates a need to revise the client's plan of care?
- A. Serum sodium 144 mEq/L.
- B. HbA1c 10%.
- C. Random serum glucose 190 mg/dL.
- D. Creatinine 1.2 mg/dL.
Correct Answer: C
Rationale: Elevated random serum glucose levels of 190 mg/dL indicate hyperglycemia and poor blood sugar control, requiring a revised plan of care. HbA1c levels above 7% also indicate long-term poor control of blood sugar. Serum sodium of 144 mEq/L and creatinine of 1.2 mg/dL are within normal ranges and do not directly indicate a need for a plan of care revision.
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A client receiving warfarin is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I will avoid eating leafy green vegetables while taking this medication.
- B. I will need to have my INR checked regularly while taking this medication.
- C. I will take this medication at the same time each day.
- D. I will avoid taking aspirin while taking this medication.
Correct Answer: D
Rationale: The correct answer is D because clients taking warfarin should avoid aspirin to reduce the risk of bleeding, as both medications can thin the blood. Choice A is incorrect because it is essential to eat a consistent amount of leafy green vegetables to maintain a steady intake of Vitamin K, which can impact warfarin's effectiveness. Choice B is incorrect although important because INR checks are necessary but do not specifically show an understanding of the teaching. Choice C is incorrect because while taking warfarin at the same time each day is beneficial for consistency, it does not directly address the interaction with aspirin.
A nurse is preparing to administer an intermittent enteral feeding to a client who has an NG tube. Which of the following actions should the nurse take?
- A. Heat the feeding to 105°F (40.6°C).
- B. Elevate the head of the bed to 45 degrees.
- C. Flush the tube with 0.9% sodium chloride.
- D. Verify the pH of the gastric aspirate.
Correct Answer: D
Rationale: Verifying the pH of the gastric aspirate is the correct action to take before administering an intermittent enteral feeding through an NG tube. This step ensures proper tube placement in the stomach, as the gastric aspirate should have an acidic pH (usually below 5). Heating the feeding solution, elevating the head of the bed, or flushing the tube with saline are not directly related to verifying tube placement and are not the immediate actions needed before administering the feeding.
A nurse is providing teaching to a client who has a new prescription for prednisone. Which of the following client statements indicates an understanding of the teaching?
- A. I will avoid crowded places to reduce my risk of infection.
- B. I will take this medication on an empty stomach.
- C. I will stop taking this medication if I experience nausea.
- D. I will take this medication for 2 weeks and then stop.
Correct Answer: A
Rationale: The correct answer is A: 'I will avoid crowded places to reduce my risk of infection.' When taking prednisone, clients should avoid crowded places to reduce the risk of infection due to its immunosuppressive effects. Choice B is incorrect because prednisone is usually taken with food to reduce stomach upset. Choice C is incorrect because clients should not stop taking prednisone abruptly, even if they experience nausea. Choice D is incorrect because prednisone should be tapered off gradually under healthcare provider guidance instead of being stopped abruptly after 2 weeks.
A nurse is caring for a client who is 1 day postoperative following a total knee replacement. The client reports pain of 8 on a scale of 0 to 10. Which of the following actions should the nurse take?
- A. Administer ibuprofen 400 mg PO
- B. Administer oxycodone 10 mg PO
- C. Reposition the client to the unaffected side
- D. Apply a cold compress to the affected knee
Correct Answer: B
Rationale: In this scenario, the appropriate action for the nurse to take when a client reports severe postoperative pain of 8 out of 10 is to administer oxycodone 10 mg PO. Oxycodone is a potent analgesic that is more effective in managing severe pain compared to ibuprofen, making choice A incorrect. Repositioning the client to the unaffected side or applying a cold compress may provide some comfort but are not the priority interventions for severe postoperative pain, making choices C and D less appropriate.
A client with schizophrenia is pacing the hall and is agitated. Which of the following actions should the nurse take?
- A. Ask the client if they intend to harm others.
- B. Tell the client to stop pacing the hall.
- C. Allow the client to pace alone until they feel less anxious.
- D. Walk with the client at a gradually slower pace.
Correct Answer: D
Rationale: The correct action for the nurse to take when caring for a client with schizophrenia who is pacing the hall and agitated is to walk with the client at a gradually slower pace. This approach can help reduce the client's agitation and prevent the situation from escalating. Choice A is incorrect because directly asking about harm may increase the client's anxiety. Choice B is inappropriate as it may worsen the client's agitation. Choice C is not recommended as the client may benefit from the nurse's presence and support during this time of distress.