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A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse?
- A. The client's capillary refill in the left toe is 6 seconds.
- B. The client has 100 mL blood in the closed-suction drain.
- C. The client has an oral temperature of 36.3° C (90.9° F).
- D. The client reports a pain level of 7 on a scale from 0 to 10 at the operative site.
Correct Answer: A
Rationale: The correct answer is A. Capillary refill time of 6 seconds in the toe indicates poor circulation, which is a concerning finding post-surgery with an external fixator. Immediate intervention is needed to prevent complications like tissue ischemia. Choices B, C, and D do not require immediate intervention as they are within normal limits postoperatively. Blood in the drain is expected, the temperature is normal, and pain level 7 is manageable with appropriate pain management.
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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.
A nurse is planning care for a client who has *Clostridium difficile* gastroenteritis. Which of the following is an appropriate nursing action?
- A. Place the client in a protective environment.
- B. Clean surfaces with chlorhexidine.
- C. Obtain a stool specimen with gloves.
- D. Wash hands with alcohol-based hand rub.
Correct Answer: C
Rationale: The correct answer is C: Obtain a stool specimen with gloves. This is important because *Clostridium difficile* is a highly contagious bacterium that spreads through fecal-oral route. By obtaining a stool specimen with gloves, the nurse can prevent the spread of the infection to themselves and others. Placing the client in a protective environment (choice A) is not necessary as standard precautions are sufficient. Cleaning surfaces with chlorhexidine (choice B) is important, but obtaining a stool specimen is a higher priority. Washing hands with alcohol-based hand rub (choice D) is important, but gloves should be used when handling stool specimens for extra protection.
A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make?
- A. These discomforts should decrease with time.'
- B. You should avoid intercourse to prevent injury to your vagina.'
- C. Women your age experience thickening of the vaginal tissue.'
- D. Your symptoms are likely due to decreasing estrogen levels.'
Correct Answer: D
Rationale: The correct answer is D: "Your symptoms are likely due to decreasing estrogen levels." This response is correct because vaginal dryness and itching are common symptoms of vaginal atrophy, which is often caused by decreased estrogen levels in older adult women. The nurse's acknowledgment and explanation of this physiological change can help the client understand the root cause of her symptoms and guide further discussion on appropriate treatment options, such as hormone therapy or vaginal moisturizers.
Choice A is incorrect because it dismisses the client's discomfort without addressing the underlying cause. Choice B is incorrect as it provides potentially harmful advice without addressing the issue. Choice C is incorrect as it inaccurately describes the condition of vaginal tissue in older women.
A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting. Which of the following medications should the nurse administer prior to chemotherapy?
- A. Selenaline
- B. Ondansetron
- C. Diphenhydramine
- D. Methylprednisolone
Correct Answer: B
Rationale: The correct answer is B: Ondansetron. Ondansetron is a commonly used antiemetic medication that helps prevent chemotherapy-induced nausea and vomiting by blocking serotonin receptors in the gastrointestinal tract and chemoreceptor trigger zone. Administering ondansetron before chemotherapy can effectively reduce the incidence of these side effects. Selenaline (A) is not a recognized medication for managing chemotherapy-induced nausea and vomiting. Diphenhydramine (C) is an antihistamine that may be used for other types of nausea but is not the first-line treatment for chemotherapy-induced nausea. Methylprednisolone (D) is a corticosteroid that may be used to reduce inflammation but is not typically used as a primary antiemetic for chemotherapy-induced nausea and vomiting.
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.