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A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Serosanguineous drainage on the surgical dressing.
- B. Temperature of 37.8°C (100°F).
- C. Urine output of 75 mL in the past 4 hours.
- D. WBC count of 15,000/mm³.
Correct Answer: D
Rationale: The correct answer is D. An elevated WBC count can indicate a potential infection, especially in a postoperative client. This finding should be reported to the provider for further evaluation and management. Choices A, B, and C are common occurrences in postoperative clients and may not necessarily indicate a severe issue. Serosanguineous drainage on the surgical dressing is a normal finding in the immediate postoperative period. A temperature of 37.8°C (100°F) can be a mild fever, which is common postoperatively due to the body's response to tissue injury. Urine output of 75 mL in the past 4 hours may be within normal limits for a postoperative client, especially if they are still recovering from anesthesia.
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A client with deep vein thrombosis receiving heparin therapy needs monitoring. Which test should the nurse use to regulate the medication dosage?
- A. Prothrombin time (PT)
- B. International Normalized Ratio (INR)
- C. Activated partial thromboplastin time (aPTT)
- D. Fibrinogen levels
Correct Answer: C
Rationale: The correct answer is C: Activated partial thromboplastin time (aPTT). aPTT is specifically used to monitor and regulate heparin therapy as it assesses the intrinsic pathway of coagulation, which heparin affects. Options A and B, Prothrombin time (PT) and International Normalized Ratio (INR), are used to monitor warfarin therapy, not heparin. Option D, Fibrinogen levels, is not the primary test used to monitor heparin therapy.
A nurse is reviewing the medical records of a client with a history of depression who is experiencing a situational crisis. What should the nurse do first?
- A. Confirm the client's perception of the event.
- B. Notify the client's support system.
- C. Help the client identify personal strengths.
- D. Teach the client relaxation techniques.
Correct Answer: A
Rationale: Confirming the client's perception of the event is crucial in understanding how they are interpreting the crisis situation. This helps the nurse gain insight into the client's perspective, emotions, and needs. By validating the client's perception, the nurse can establish trust and rapport, which are essential in providing effective support during a crisis. Notifying the client's support system (Choice B) may be important but should come after understanding the client's perspective. Helping the client identify personal strengths (Choice C) and teaching relaxation techniques (Choice D) are valuable interventions but should follow the initial step of confirming the client's perception to ensure individualized care.
A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provide to the client?
- A. Personal blogs about managing the adverse effects of diabetes medications.
- B. Food label recommendations from the Institute of Medicine.
- C. Diabetes medication information from the Physicians' Desk Reference.
- D. Food exchange lists for meal planning from the American Diabetes Association.
Correct Answer: D
Rationale: The correct answer is D. Food exchange lists from the American Diabetes Association are valuable resources for individuals with diabetes as they provide specific guidance on meal planning and portion control, which are crucial for managing blood sugar levels. Choice A is incorrect because personal blogs may not always provide accurate or evidence-based information. Choice B is incorrect as food label recommendations, while important, may not offer the structured guidance needed for meal planning in diabetes. Choice C is also incorrect as medication information is different from dietary guidance needed for diabetes management.
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.
A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis (DKA). Which of the following findings should the nurse report to the provider?
- A. Potassium 4.2 mEq/L
- B. Glucose 250 mg/dL
- C. Bicarbonate 20 mEq/L
- D. Sodium 135 mEq/L
Correct Answer: B
Rationale: The correct answer is B. A glucose level of 250 mg/dL indicates hyperglycemia, which is expected in DKA. However, in the context of DKA management, persistent or worsening hyperglycemia can indicate inadequate treatment response or complications, necessitating further monitoring and intervention. Potassium levels are crucial in DKA due to the risk of hypokalemia, but a level of 4.2 mEq/L is within the normal range. Bicarbonate levels are typically low in DKA, making a value of 20 mEq/L consistent with the condition. Sodium levels of 135 mEq/L are also within normal limits and not a priority for immediate reporting in the context of DKA.