Nokea
A home health nurse is reviewing the laboratory results for several clients with heart failure. Which client finding would the nurse report to the health care provider immediately?
- A. total cholesterol 190
- B. glycosylated hemoglobin of 7%
- C. B-type natriuretic peptide 550 pg/ml (more than 100 is bad)
- D. potassium 3.7
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A female client is admitted with a tentative diagnosis of Guillain-Barre syndrome. Which finding is most important for the nurse to report to the healthcare provider?
- A. Facial weakness and difficulty speaking.
- B. Decreased deep tendon reflexes in the legs.
- C. Inability to move the eyes.
- D. Respiratory distress and cyanosis.
Correct Answer: B
Rationale: In Guillain-Barre syndrome, decreased deep tendon reflexes are a critical finding that may indicate impending respiratory failure. This is due to the involvement of the peripheral nervous system affecting the muscles, including those involved in breathing. Reporting decreased deep tendon reflexes promptly is essential to prevent respiratory compromise. Facial weakness, difficulty speaking, and inability to move the eyes are common manifestations of Guillain-Barre syndrome but are not as immediately concerning as respiratory distress and impending respiratory failure.
A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, 'Why do you have to wear a gown and mask when you are in my room?' How should the nurse respond?
- A. To protect myself from your germs.
- B. To protect you because you can get an infection very easily.
- C. Until your white blood cell count increases.
- D. To keep others from getting your infection.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The communi ty health nurse is planning a series of educational courses about the heal thcare system and meeti ng heal thcare needs for t he community center. Which adjunct issue shoul d the nurs e address for a group of ol der adul ts.
- A. peer concerns
- B. adul t daycare
- C. reti rement i ssues
- D. vocati onal concerns -
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is providing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding requires immediate intervention?
- A. Serum sodium of 140 mEq/L.
- B. Serum osmolality of 280 mOsm/kg.
- C. Weight gain of 2 pounds in 24 hours.
- D. Serum sodium of 130 mEq/L.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is caring for a client with diabetic ketoacidosis (DKA). Which laboratory result requires immediate intervention?
- A. Blood glucose of 250 mg/dL.
- B. Serum potassium of 3.5 mEq/L.
- C. Serum sodium of 135 mEq/L.
- D. Arterial blood pH of 7.30.
Correct Answer: D
Rationale: Corrected Rationale: An arterial blood pH of 7.30 indicates the client is in acidosis, which is a life-threatening condition in DKA. Immediate intervention is required to correct the acidosis and prevent further complications such as organ failure or coma. Blood glucose of 250 mg/dL is elevated but not an immediate threat to life in comparison to acidosis. Serum potassium of 3.5 mEq/L and serum sodium of 135 mEq/L are within normal ranges and do not warrant immediate intervention in the context of DKA.