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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.
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A nurse is caring for a client who is experiencing an exacerbation of heart failure. Which of the following findings indicate potential improvement?
- A. Hgb 8.4 g/dL (12 to 18 g/dL)
- B. Hct 42% (37% to 47%)
- C. WBC count 9
- D. Potassium 4.3 mEq/L (3.5 to 5 mEq/L)
Correct Answer: D
Rationale: The correct answer is D: Potassium 4.3 mEq/L (3.5 to 5 mEq/L). In heart failure exacerbation, potassium levels can be affected due to medications or fluid shifts. A potassium level within the normal range indicates electrolyte balance, which is crucial for cardiac function. Hemoglobin (Choice A) and hematocrit (Choice B) are indicators of oxygen-carrying capacity and volume status, not directly related to heart failure improvement. White blood cell count (Choice C) is not specific to heart failure exacerbation. Therefore, the correct answer is D as it reflects a positive change in electrolyte balance, essential for cardiac function.
A nurse is planning care for a client who has a cervical spine injury and has a halo traction device in place. Which of the following actions should the nurse plan to take?
- A. Apply medicated powder under the vest to reduce itching.
- B. Move the client up and down in bed by holding onto the halo traction device.
- C. Ensure that there is space for one finger to fit between the vest and the client's skin.
- D. Locate or tighten the screws on the device as needed for the client's comfort.
Correct Answer: C
Rationale: The correct answer is C: Ensure that there is space for one finger to fit between the vest and the client's skin. This is important to prevent pressure ulcers and skin breakdown. Tight vest can lead to skin irritation. Applying medicated powder (A) may further irritate the skin. Moving the client by holding the halo traction device (B) can lead to dislodgement or injury. Locating or tightening screws (D) should only be done by healthcare providers to prevent complications.
A nurse is caring for a client who has cervical cancer and is receiving internal radiation therapy. Which of the following actions should the nurse take?
- A. Check if the radioactive device is in the correct position.
- B. Limit time for visitors to 2 hours per day.
- C. Ask visitors to remain 3 feet from the client.
- D. Keep lead-lined aprons in the client's room.
Correct Answer: A
Rationale: The correct action for the nurse to take is to check if the radioactive device is in the correct position. This is crucial to ensure that the radiation therapy is being delivered accurately and effectively. By verifying the position of the radioactive device, the nurse can prevent potential harm to the client and ensure the success of the treatment.
Choice B is incorrect because limiting visitors' time does not directly relate to the safety and effectiveness of the radiation therapy. Choice C is incorrect as asking visitors to remain 3 feet away does not address the primary concern of verifying the device's position. Choice D is also incorrect as lead-lined aprons are typically used by healthcare providers during procedures, not by the client.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following nursing actions isn't appropriate?
- A. Monitor serum blood glucose during infusion.
- B. Obtain the client's weight daily.
- C. Infuse 0.9% sodium chloride if the solution is not available.
- D. Verify the solution with another RN prior to infusion.
Correct Answer: C
Rationale: Correct Answer: C - Infuse 0.9% sodium chloride if the solution is not available.
Rationale: TPN is a specialized form of nutrition that must be administered precisely as prescribed to prevent complications. Infusing 0.9% sodium chloride instead of the prescribed TPN solution can lead to imbalanced nutrient intake and electrolyte disturbances. It is crucial to follow the prescribed TPN regimen accurately to meet the client's specific nutritional needs.
Incorrect Choices:
A: Monitoring serum blood glucose during infusion is appropriate to ensure the client's glycemic control while on TPN.
B: Obtaining the client's weight daily is important to assess fluid status and adjust the TPN prescription as needed.
D: Verifying the TPN solution with another RN prior to infusion is a standard safety practice to prevent errors in administration.
A nurse is reviewing the medical record of a client who has nephrotic syndrome. Which of the following findings should the nurse expect?
- A. Hyperalbuminemia
- B. Proteinuria
- C. Decreased serum lipid levels
- D. Decreased coagulation
Correct Answer: B
Rationale: The correct answer is B: Proteinuria. In nephrotic syndrome, there is increased permeability of the glomerular filtration membrane, leading to excessive loss of proteins in the urine, specifically albumin. This results in proteinuria. Choice A, hyperalbuminemia, is incorrect as nephrotic syndrome actually causes hypoalbuminemia due to protein loss. Choice C, decreased serum lipid levels, is incorrect because nephrotic syndrome causes hyperlipidemia due to increased hepatic synthesis of lipoproteins. Choice D, decreased coagulation, is incorrect as nephrotic syndrome is associated with hypercoagulability due to loss of anticoagulant proteins in the urine.