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A nurse is admitting a client who has arthritis pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor?
- A. Serum calcium
- B. Stool for occult blood
- C. Fasting blood glucose
- D. Urine for white blood cells
Correct Answer: B
Rationale: The correct answer is B: Stool for occult blood. Long-term use of ibuprofen can lead to gastrointestinal bleeding, which may not always present with visible blood in the stool. Monitoring for occult blood helps detect this potential side effect early. Choices A, C, and D are not directly related to the adverse effects of ibuprofen use. Serum calcium is not typically affected by ibuprofen. Fasting blood glucose monitoring is more relevant for medications affecting glucose metabolism. Urine for white blood cells is not a common test for monitoring the side effects of ibuprofen.
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A nurse is planning care for a client who has a cervical spine injury and has a halo traction device in place. Which of the following actions should the nurse plan to take?
- A. Apply medicated powder under the vest to reduce itching.
- B. Move the client up and down in bed by holding onto the halo traction device.
- C. Ensure that there is space for one finger to fit between the vest and the client's skin.
- D. Locate or tighten the screws on the device as needed for the client's comfort.
Correct Answer: C
Rationale: The correct answer is C: Ensure that there is space for one finger to fit between the vest and the client's skin. This is important to prevent pressure ulcers and skin breakdown. Tight vest can lead to skin irritation. Applying medicated powder (A) may further irritate the skin. Moving the client by holding the halo traction device (B) can lead to dislodgement or injury. Locating or tightening screws (D) should only be done by healthcare providers to prevent complications.
A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
- A. Ask a family member to be present during the admission.
- B. Request an interpreter during the initial assessment.
- C. Familiarize themselves with commonly used sign language.
- D. Obtain a board that uses colored pictures as communication.
Correct Answer: B
Rationale: The correct answer is B: Request an interpreter during the initial assessment. This is the best option because it ensures effective communication between the nurse and the client. By having a professional interpreter present, the nurse can accurately gather information, provide instructions, and address any concerns the client may have. Asking a family member to be present (A) may not guarantee accurate communication. Familiarizing with sign language (C) may not be sufficient for complex medical discussions. Using a board with pictures (D) may not be effective for detailed conversations.
A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take?
- A. Obtain the client's vital signs.
- B. Perform a neurologic check.
- C. Turn the client on their side.
- D. Notify the rapid response team.
Correct Answer: C
Rationale: The correct action is to turn the client on their side (Choice C) during a tonic-clonic seizure to prevent aspiration and maintain a clear airway. This position helps saliva or vomit to drain out of the mouth, reducing the risk of choking. Obtaining vital signs (Choice A) and performing a neurologic check (Choice B) can wait until after the seizure is over. Notifying the rapid response team (Choice D) is not necessary for a single seizure unless complications arise.
A nurse is reviewing the laboratory findings of a client who has a new diagnosis of Graves' disease. The nurse should anticipate which of the following laboratory values to be elevated?
- A. Triiodothyronine
- B. Phosphorus
- C. Calcium
- D. Thyroid-stimulating hormone
Correct Answer: A
Rationale: The correct answer is A: Triiodothyronine. In Graves' disease, there is overproduction of thyroid hormones, including triiodothyronine (T3). Elevated T3 levels are characteristic due to increased thyroid hormone synthesis and release. Triiodothyronine is the active form of thyroid hormone, affecting metabolism, heart rate, and other body functions. Phosphorus (B), calcium (C), and thyroid-stimulating hormone (D) are not typically elevated in Graves' disease. Phosphorus and calcium levels may be normal or even decreased, as the disease primarily affects thyroid hormone levels. Thyroid-stimulating hormone is usually suppressed in Graves' disease due to the negative feedback mechanism of high thyroid hormone levels.
A nurse is providing teaching for a client who is taking isoniazid (INH) for tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?
- A. I plan to take this medication for 1 week.'
- B. I should take an antacid with each dose of this medication.'
- C. This medication may cause my blood pressure to increase.'
- D. I will have my liver function tested while I am taking this medication.'
Correct Answer: D
Rationale: The correct answer is D: "I will have my liver function tested while I am taking this medication." This answer demonstrates understanding because isoniazid (INH) is known to potentially cause liver toxicity. Regular monitoring of liver function is essential to detect any adverse effects early. Option A is incorrect as INH treatment typically lasts for several months, not just 1 week. Option B is incorrect as antacids can decrease the absorption of INH. Option C is incorrect as INH does not typically cause an increase in blood pressure.