Nokea
A nurse is caring for a client who has dysphagia following a stroke. The nurse should recommend a referral to which of the following members of the interdisciplinary team?
- A. Speech therapist
- B. Respiratory therapist
- C. Occupational therapist
- D. Physical therapist
Correct Answer: A
Rationale: A speech therapist addresses dysphagia by assessing swallowing and recommending strategies, critical after a stroke. Other therapists focus on different rehabilitation aspects.
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Medication Administration Record
Ceftriaxone 2 gm IV BID
Acetaminophen 325 mg PO every 4 hr PRN fever over 39° C (102.2° F)
Guaifenesin 200 mg PO every 4 hr PRN cough
Diagnostic Results
Complete Blood Count:
Hemoglobin 15 g/dL (12 to 16 g/dL)
Hematocrit 45% (37% to 47%)
WBC count 15,000/mm* (5000 to 10,000/mm*)
Basic Metabolic Profile:
Creatinine 2.8 mg/dL (0.5 to 1.1 mg/di)
BUN 19 mg/dL (10 to 20 mg/dL)
Sputum Culture and Sensitivity:
Klebsiella pneumonia
A nurse is reviewing the medical record of a client who has pneumonia. Which of the following information is the priority for the nurse report to the provider?
- A. Sputum results
- B. Creatinine level
- C. Temperature
- D. WBC count
- E. Oxygen saturation
- F. Blood pressure
- G. Respiratory rate
Correct Answer: B
Rationale: Elevated creatinine (2.8 mg/dL) indicates potential kidney injury, a priority over sputum (expected Klebsiella), WBC (infection), or temperature.
A nurse is caring for a client who has a distal radius fracture with a short arm cast applied. Which of the following actions should the nurse take?
- A. Use a hair dryer to blow hot air into the cast to relieve itching.
- B. Perform neurovascular checks of the affected extremity every 2 hr.
- C. Position the fractured arm below the level of the client's heart.
- D. Immobilize the client's fingers using a hand splint.
Correct Answer: B
Rationale: Neurovascular checks every 2 hours assess circulation and nerve function, critical after cast application. Hot air can burn, elevation reduces swelling, and finger immobilization isn't standard unless specified.
A nurse is contributing to the plan of care for a client who has viral meningitis. Which of the following interventions should the nurse recommend?
- A. Measure the client's intake and output every 8 hr.
- B. Dim the lighting in the client's room.
- C. Monitor the client's temperature every 6 hr.
- D. Initiate contact precautions for the client.
Correct Answer: B
Rationale: Dimming the lighting reduces photophobia, a common symptom of viral meningitis, improving client comfort. Intake/output and temperature monitoring are useful but less specific, and contact precautions are not typically required for viral meningitis.
A nurse is reinforcing teaching about risk factors for colorectal cancer with a client. Which of the following risk factors should the nurse include in the teaching?
- A. Physical inactivity
- B. Family history of colorectal cancer
- C. High-fiber diet
- D. Age over 50 years
- E. History of diabetes mellitus
Correct Answer: B
Rationale: Colorectal cancer risk factors are well-documented, with family history being a major non-modifiable contributor due to genetic predisposition (e.g., Lynch syndrome). Physical inactivity increases risk by slowing bowel motility, allowing carcinogen exposure, but it's less definitive than genetics. A high-fiber diet reduces risk by promoting regular bowel movements, not increasing it, so it's incorrect here. Age over 50 is a strong risk factor as incidence rises with age, but family history often trumps it in teaching specificity due to its hereditary link. Emphasizing family history educates the client on screening needs (e.g., earlier colonoscopy), aligning with guidelines like those from the American Cancer Society. It's a critical, actionable factor, driving personalized prevention and surveillance, making it a standout choice for inclusion in teaching.
A nurse is preparing to administer filgrastim 6 mcg/kg subcutaneously to a client who weighs 110 lb. Available is filgrastim solution for injection 480 mcg/0.8 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 0.3 mL
- B. 0.4 mL
- C. 0.5 mL
- D. 0.6 mL
Correct Answer: C
Rationale: To calculate the correct dose, convert the client's weight from pounds to kilograms (110 lb ÷ 2.2 = 50 kg). Filgrastim is dosed at 6 mcg/kg, so 6 mcg/kg × 50 kg = 300 mcg needed. The available concentration is 480 mcg in 0.8 mL. Set up the proportion: (300 mcg ÷ 480 mcg) × 0.8 mL = 0.5 mL. Option A (0.3 mL) underdoses at 180 mcg, Option B (0.4 mL) gives 240 mcg, and Option D (0.6 mL) overdoses at 360 mcg. Option C (0.5 mL) delivers exactly 300 mcg, matching the prescribed dose. Rounding to the nearest tenth, 0.5 mL is correct with no trailing zero, adhering to medication safety standards. This calculation ensures therapeutic efficacy (e.g., boosting white blood cells) while minimizing risks like overdose-related bone pain or underdose-related infection susceptibility, making C the precise and safe choice.