Nokea
A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests?
- A. Platelet count
- B. Potassium level
- C. Creatinine clearance
- D. Prealbumin
Correct Answer: A
Rationale: The correct answer is A: Platelet count. Platelet count helps assess clotting abnormalities that could cause petechiae and ecchymoses. Petechiae and ecchymoses are often associated with bleeding disorders, so it is crucial to evaluate the platelet count to determine if there is a deficiency in platelets. Choices B, C, and D are incorrect because potassium level, creatinine clearance, and prealbumin do not directly relate to assessing clotting abnormalities associated with petechiae and ecchymoses.
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A healthcare provider is providing dietary teaching to a client who has osteoporosis. Which of the following foods should the healthcare provider recommend as the best source of calcium?
- A. Broccoli
- B. Cheddar cheese
- C. Almonds
- D. Fortified orange juice
Correct Answer: B
Rationale: Cheddar cheese is a rich source of calcium and should be recommended to clients with osteoporosis. While broccoli and almonds also contain calcium, cheddar cheese provides a higher amount per serving. Fortified orange juice may contain added calcium, but it is not as concentrated a source as cheddar cheese. Therefore, the best choice for a client with osteoporosis seeking a high calcium food is cheddar cheese.
A client with schizophrenia is experiencing delusions. Which of the following interventions should the nurse implement?
- A. Tell the client that their delusions are not real
- B. Encourage the client to explore the meaning behind their delusions
- C. Focus on the client's feelings rather than the delusions
- D. Challenge the client's delusions directly
Correct Answer: C
Rationale: In caring for a client with schizophrenia experiencing delusions, it is essential to focus on the client's feelings rather than directly addressing or challenging the delusions. By focusing on the client's emotions, the nurse can build trust and rapport without reinforcing the delusions. Choice A is incorrect because directly telling the client that their delusions are not real may lead to confrontation or mistrust. Choice B is incorrect as encouraging exploration of the delusions may further validate them. Choice D is incorrect because challenging the client's delusions can escalate the situation and damage the therapeutic relationship.
A client reports intimate partner violence to a nurse. What is the nurse's priority action?
- A. Develop a safety plan with the client.
- B. Refer the client to a community support group.
- C. Determine if the client has any injuries.
- D. Ensure the client has access to legal services.
Correct Answer: A
Rationale: The correct answer is to develop a safety plan with the client. When a client reports intimate partner violence, the priority is ensuring their immediate safety. Developing a safety plan involves identifying safe places, emergency contacts, and strategies to protect the client from harm. Referring the client to a community support group (Choice B) can be helpful but not the immediate priority. While determining if the client has any injuries (Choice C) is important for assessing their physical well-being, the priority is to ensure their safety. Ensuring the client has access to legal services (Choice D) is crucial, but it is not the immediate priority when the client is at risk of violence.
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Serous drainage at the incision site
- B. Temperature 38.2°C (100.8°F)
- C. Heart rate 92/min
- D. Blood pressure 130/80 mm Hg
Correct Answer: B
Rationale: The correct answer is B. An elevated temperature of 38.2°C (100.8°F) indicates a potential infection and should be reported to the provider. Elevated temperature postoperatively is often a sign of infection or inflammation, which can delay healing and increase the risk of complications. Choices A, C, and D are within normal ranges for a postoperative client and do not indicate an immediate need for reporting to the provider. Serous drainage at the incision site is expected in the initial postoperative period as part of the normal healing process, a heart rate of 92/min can be a normal response to surgery due to stress or pain, and a blood pressure of 130/80 mm Hg is also within normal limits for most clients.
A nurse is caring for a 1-day-old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take?
- A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
- B. Keep the infant's head uncovered.
- C. Ensure that the newborn wears a diaper.
- D. Apply lotion to the newborn every 4 hours.
Correct Answer: C
Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent irritation during phototherapy, as exposure to light can increase the risk of skin breakdown. Feeding the infant glucose water is unnecessary and not indicated for jaundice treatment. Keeping the infant's head uncovered allows the light to reach the skin effectively. Applying lotion to the newborn every 4 hours can interfere with the effectiveness of phototherapy and is not recommended.