Nokea
A healthcare professional is reviewing the laboratory results of a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the professional report to the provider?
- A. Blood glucose level of 130 mg/dL
- B. Serum sodium level of 140 mEq/L
- C. Serum potassium level of 3.2 mEq/L
- D. Platelet count of 250,000/mm³
Correct Answer: C
Rationale: A serum potassium level of 3.2 mEq/L indicates hypokalemia, a complication that should be reported in clients receiving TPN. Hypokalemia can lead to serious cardiac and neuromuscular complications. The other options are within normal ranges and do not indicate immediate concerns for a client receiving TPN. A blood glucose level of 130 mg/dL, serum sodium level of 140 mEq/L, and platelet count of 250,000/mm³ are all considered normal values and do not require immediate intervention.
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What is the most important nursing action when a patient experiences a fall?
- A. Assess the patient for injuries
- B. Call for help
- C. Document the fall
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The most important nursing action when a patient experiences a fall is to assess the patient for injuries. This is critical to identify any potential harm or underlying issues that may require immediate attention. Calling for help and notifying the healthcare provider are important steps, but assessing the patient's condition takes precedence to ensure prompt and appropriate care. Documenting the fall is also necessary but should follow the initial assessment and care provided to the patient.
Which electrolyte imbalance should be closely monitored in a patient receiving digoxin?
- A. Monitor potassium levels
- B. Monitor sodium levels
- C. Monitor calcium levels
- D. Monitor glucose levels
Correct Answer: A
Rationale: Corrected Rationale: Potassium levels should be monitored closely in a patient receiving digoxin to avoid hypokalemia. Digoxin can increase the risk of developing life-threatening arrhythmias in the presence of low potassium levels. Monitoring sodium, calcium, or glucose levels is not specifically necessary for patients on digoxin, making choices B, C, and D incorrect.
A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?
- A. Holding the newborn in an en face position
- B. Asking the father to change the newborn's diaper
- C. Requesting the nurse to take the newborn to the nursery so she can rest
- D. Viewing the newborn's actions as uncooperative
Correct Answer: D
Rationale: The correct answer is D because viewing the newborn's actions as uncooperative indicates a lack of bonding, which requires intervention. Choices A, B, and C all involve appropriate and caring actions by the client towards the newborn. Holding the newborn in an en face position promotes bonding, involving the father in caring for the newborn is beneficial for family involvement, and requesting rest by asking the nurse to take the newborn to the nursery is a responsible action to ensure both the client and the newborn get adequate rest.
A nurse is providing discharge instructions for a client who has osteoporosis. Which of the following instructions should the nurse include to prevent injury?
- A. Perform weight-bearing exercises.
- B. Avoid crossing the legs beyond the midline.
- C. Avoid sitting in one position for prolonged periods.
- D. Splint the affected area.
Correct Answer: A
Rationale: The correct answer is A: Perform weight-bearing exercises. Weight-bearing exercises are crucial for preventing bone density loss in clients with osteoporosis. These exercises help strengthen bones and reduce the risk of fractures. Option B, avoiding crossing the legs beyond the midline, is not directly related to preventing injury in osteoporosis. Option C, avoiding sitting in one position for prolonged periods, is important for preventing pressure ulcers but does not specifically address preventing injury in osteoporosis. Option D, splinting the affected area, is not a standard recommendation for preventing injury in osteoporosis.
A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the therapy?
- A. Serum potassium
- B. Platelets
- C. aPTT
- D. INR
Correct Answer: C
Rationale: The correct answer is C: aPTT. Monitoring the activated partial thromboplastin time (aPTT) is crucial when a client is receiving heparin therapy. The aPTT reflects the clotting time and helps assess the effectiveness of heparin in preventing clot formation. Keeping the aPTT within the therapeutic range ensures that the medication is working optimally. Choices A, B, and D are incorrect because serum potassium, platelets, and INR are not direct indicators of heparin's effectiveness or therapeutic range.