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A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?
- A. Breath sounds
- B. Client's history of smoking
- C. Current medication list
- D. Client's family history of respiratory illness
Correct Answer: A
Rationale: In a client with pneumonia, assessing breath sounds is crucial as it provides immediate information about the client's respiratory status. Changes in breath sounds could indicate complications like fluid accumulation or worsening pneumonia. While the client's history of smoking (Choice B), current medication list (Choice C), and family history of respiratory illness (Choice D) are important factors to consider, they are not as urgent or directly related to the client's immediate condition as assessing breath sounds.
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A client is receiving chemotherapy for breast cancer. Which laboratory value would be most important for the nurse to monitor?
- A. White blood cell count
- B. Hemoglobin level
- C. Serum creatinine
- D. Blood glucose level
Correct Answer: A
Rationale: The correct answer is to monitor the white blood cell count. Chemotherapy can lead to neutropenia, which is a decrease in white blood cells, particularly neutrophils. Neutropenia increases the risk of infections, making it crucial to monitor the white blood cell count during chemotherapy. Monitoring hemoglobin level is important but not as critical as white blood cell count in this scenario. Serum creatinine and blood glucose levels are not directly impacted by chemotherapy for breast cancer, making them less relevant to monitor in this situation.
A client with congestive heart failure (CHF) is receiving furosemide (Lasix). Which laboratory value should the LPN monitor closely while the client is taking this medication?
- A. Sodium
- B. Potassium
- C. Calcium
- D. Magnesium
Correct Answer: B
Rationale: The LPN should monitor potassium levels closely while the client is taking furosemide (Lasix) due to the medication's potential to cause hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss through increased urine output. Hypokalemia can result in serious complications such as cardiac dysrhythmias. Monitoring sodium levels (choice A) is important but not as critical as monitoring potassium in this context. Calcium (choice C) and magnesium (choice D) levels are not typically affected by furosemide and are not the priority for monitoring in this scenario.
The healthcare provider attaches a pulse oximeter to a client's fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?
- A. BP 142/88 mmHg
- B. 2+ edema of fingers and hands
- C. Radial pulse volume is +3
- D. Capillary refill time is 2 seconds
Correct Answer: B
Rationale: Edema, indicated by 2+ edema of fingers and hands, can impair blood flow and peripheral perfusion, leading to reduced oxygen saturation readings on a pulse oximeter. High blood pressure (choice A) would not directly affect oxygen saturation readings. Radial pulse volume (choice C) and capillary refill time (choice D) are more related to assessing circulation rather than contributing significantly to oxygen saturation readings.
A healthcare professional uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking did the healthcare professional demonstrate?
- A. Confidence
- B. Perseverance
- C. Integrity
- D. Discipline
Correct Answer: D
Rationale: The correct answer is 'Discipline.' In this scenario, discipline is exemplified by following a structured and comprehensive assessment process, as seen in the head-to-toe approach. Confidence (choice A) relates to self-assurance and belief in one's abilities, which is not the primary critical thinking demonstrated in this situation. Perseverance (choice B) is the persistence in achieving goals despite challenges, not directly related to the systematic assessment process. Integrity (choice C) pertains to honesty and ethical behavior, which are important traits but not the critical thinking skill exemplified by the structured assessment process shown in the head-to-toe approach.
A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority?
- A. "I kind of like this boy in my class, but he doesn't like me back."
- B. "I want to hang out with the kids in the science club, but the jocks pick on them."
- C. "I am so fat, I skip meals to try to lose weight."
- D. "My dad wants me to be a lawyer like him, but I just want to dance."
Correct Answer: C
Rationale: The correct answer is C. Skipping meals to lose weight may indicate an eating disorder or significant distress, which can have serious health implications. This behavior raises concerns about the adolescent's physical and mental well-being. The nurse should prioritize addressing potential eating disorders and body image issues in this situation. Choices A, B, and D, while important, do not pose an immediate risk to the adolescent's health or well-being compared to the potential consequences of disordered eating behavior.