Nokea
A nurse is reinforcing teaching about laboratory testing with a client. Which of the following findings should the nurse include as an indicator of infection?
- A. Decreased platelets
- B. Increased iron level
- C. Increased erythrocyte sedimentation rate
- D. Decreased hemoglobin
Correct Answer: C
Rationale: Increased ESR indicates inflammation, often due to infection. Platelet or hemoglobin decreases or iron increases aren't specific to infection.
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A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?
- A. Countertransference
- B. Boundary crossing
- C. Promoting trust
- D. Veracity
Correct Answer: C
Rationale: Providing a meal addresses the client's immediate need, fostering trust and rapport. This action reflects responsiveness, not countertransference, boundary crossing, or truthfulness.
A nurse is reinforcing teaching with a client who has a new prescription for metoprolol. Which of the following statements should the nurse include?
- A. Take this medication with a high-fiber meal.
- B. You might feel tired while taking this medication.
- C. You need to avoid caffeine.
- D. You can stop taking this medication if your pulse is normal.
Correct Answer: B
Rationale: Metoprolol can cause fatigue, a side effect to anticipate. Fiber meals, caffeine avoidance, and stopping based on pulse aren't recommended.
A nurse is caring for a client who is receiving IV heparin. Which of the following actions should the nurse take?
- A. Monitor the client's prothrombin time (PT).
- B. Administer the heparin via IV push.
- C. Check the client's activated partial thromboplastin time (aPTT).
- D. Instruct the client to increase vitamin K intake.
Correct Answer: C
Rationale: Heparin's effect is monitored via aPTT to ensure therapeutic anticoagulation. PT is for warfarin, heparin infuses slowly, and vitamin K counteracts it.
A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?
- A. I can remove my security band to give it to a family member.
- B. I will carry my baby to the nursery.
- C. I will have an identification band that matches the one my baby wears.
- D. I can take my baby to the lobby to visit family.
Correct Answer: C
Rationale: Matching identification bands ensure mother and baby are correctly paired, a key security measure. Removing bands, carrying to the nursery, or taking the baby to public areas risks safety.
A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?
- A. An incident report has been completed and sent to risk management.
- B. Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom.'
- C. The client fell because the assistive personnel did not place nonskid slippers on the client.
- D. The client does not appear to have any injuries resulting from the fall.
Correct Answer: B
Rationale: Documenting the client's statement provides an accurate account of the incident. Incident reports, blame, or injury absence are inappropriate for the medical record.