Nokea
A healthcare professional is reviewing the laboratory results of a client who is receiving chemotherapy. Which of the following findings should the healthcare professional report immediately?
- A. White blood cell count of 4,500/mm³
- B. Hemoglobin level of 8 g/dL
- C. Platelet count of 90,000/mm³
- D. Serum potassium level of 3.5 mEq/L
Correct Answer: C
Rationale: A platelet count of 90,000/mm³ indicates thrombocytopenia, which increases the risk of bleeding and requires immediate intervention. Thrombocytopenia can lead to serious bleeding complications, so it is crucial to address this finding promptly. A low white blood cell count (choice A) may indicate neutropenia but is not as immediately life-threatening as severe thrombocytopenia. A hemoglobin level of 8 g/dL (choice B) would require intervention but is not as urgent as addressing a critically low platelet count. A serum potassium level of 3.5 mEq/L (choice D) is on the lower side of normal but does not pose an immediate risk to the client's safety compared to severe thrombocytopenia.
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A nurse is assessing a client who is at 34 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse report to the provider?
- A. Blood pressure of 140/90 mm Hg
- B. Fasting blood glucose of 120 mg/dL
- C. Urinary output of 40 mL/hr
- D. Weight gain of 2.3 kg (5 lb) in 1 week
Correct Answer: D
Rationale: A weight gain of 2.3 kg (5 lb) in 1 week can indicate worsening gestational hypertension and should be reported to the provider. Sudden weight gain in a client with gestational hypertension can be a sign of fluid retention, which could worsen the hypertension and lead to complications like preeclampsia. The other options, blood pressure of 140/90 mm Hg, fasting blood glucose of 120 mg/dL, and urinary output of 40 mL/hr, are within normal limits for a client with gestational hypertension and do not pose an immediate concern that requires reporting to the provider.
What is the appropriate intervention when a patient experiences a fall?
- A. Assess for injuries
- B. Call for help
- C. Document the fall
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The appropriate intervention when a patient experiences a fall is to assess for injuries. This immediate action helps in identifying any harm or complications resulting from the fall, allowing for timely intervention. Calling for help may be necessary after assessing the injuries, but the priority is to evaluate the patient's condition. Documenting the fall is important for record-keeping purposes but should come after ensuring the patient's safety. Notifying the healthcare provider can be done once the assessment has been completed and any necessary initial interventions have been initiated.
A nurse is reviewing the medical record of a client who is at 30 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 140/90 mm Hg
- B. 1+ pitting edema in the lower extremities
- C. Weight gain of 2.3 kg (5 lb) in 1 week
- D. Mild headache
Correct Answer: C
Rationale: A weight gain of 2.3 kg (5 lb) in 1 week can indicate worsening preeclampsia due to fluid retention, which can lead to serious complications. This finding should be reported promptly to the provider for further assessment and intervention. Blood pressure of 140/90 mm Hg is high but may not be an immediate concern for a client with preeclampsia at 30 weeks. 1+ pitting edema in the lower extremities is common in pregnancy, especially in the third trimester, and may not be a significant finding in isolation. A mild headache can be a common symptom in pregnancy and may not be indicative of worsening preeclampsia unless accompanied by other concerning signs.
What is the appropriate diet for a patient with chronic kidney disease?
- A. Low protein diet
- B. High protein diet
- C. Low sodium diet
- D. Low potassium diet
Correct Answer: A
Rationale: A low protein diet is the appropriate choice for a patient with chronic kidney disease because it helps to reduce the buildup of waste products in the body, which the kidneys may struggle to filter out. High protein diets can put extra strain on the kidneys by increasing the workload to eliminate the byproducts of protein metabolism. While low sodium and low potassium diets can also be important for managing certain aspects of kidney disease, the primary focus should be on controlling protein intake to lessen the burden on the kidneys.
A patient refused a newly opened fentanyl patch. Which of the following actions should the nurse take?
- A. Ask another nurse to witness the disposal of the new patch
- B. Dispose of the patch in a sharps container
- C. Send the patch back to the pharmacy
- D. Document the refusal and remove the patch
Correct Answer: A
Rationale: When a patient refuses a newly opened fentanyl patch, the nurse should ask another nurse to witness the disposal of the new patch. This action ensures accountability, proper protocol, and prevents any potential diversion or misuse of the medication. Disposing of the patch in a sharps container (Choice B) is not sufficient as it does not address the need for witness accountability. Sending the patch back to the pharmacy (Choice C) may not be appropriate without proper documentation and witness. Simply documenting the refusal and removing the patch (Choice D) may lack the necessary verification of proper disposal.