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A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?
- A. Sodium 130 mEq/L
- B. Creatinine 1.0 mg/dL
- C. Sodium 135 mEq/L
- D. Potassium 5.4 mEq/L
Correct Answer: A
Rationale: The correct answer is A: Sodium 130 mEq/L. A sodium level of 130 mEq/L is considered hyponatremia, which can indicate potential fluid imbalance or certain health conditions. The nurse should report this finding to the provider for further evaluation and intervention.
Choices B, C, and D fall within normal reference ranges for creatinine, sodium, and potassium levels, respectively. Therefore, they do not require immediate reporting.
In summary, the nurse should report a low sodium level (A) as it can be clinically significant, while the other choices are within normal limits and do not warrant immediate action.
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A nurse is admitting a client to a healthcare facility. The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
- A. Wear an N95 mask when caring for the client.
- B. Place a container for soiled linens inside the client's room.
- C. Place the client in a negative airflow room.
- D. Remove mask after exiting the client's room.
- E. Wear a sterile water-resistant gown if within 3 feet of the client.
Correct Answer: A, B, C, E
Rationale: The correct answers are A, B, C, and E.
A: Wearing an N95 mask is crucial to prevent the spread of airborne infections.
B: Placing a container for soiled linens inside the room prevents contamination of other areas.
C: Placing the client in a negative airflow room helps contain infectious particles.
E: Wearing a gown within 3 feet of the client prevents exposure to bodily fluids.
D: Removing the mask after exiting the room increases the risk of contamination.
False options would include not utilizing an N95 mask, not isolating soiled linens, not placing the client in a negative airflow room, and not wearing appropriate PPE when close to the client.
A nurse in a provider's clinic is caring for a client who has diarrhea. The nurse is providing teaching for the client. Select the 4 instructions the nurse should include in the teaching.
- A. Increase intake of high-calcium foods.
- B. Eat probiotic foods, such as yogurt.
- C. Avoid alcohol while experiencing diarrhea.
- D. Eat raw vegetables.
- E. Eat three large meals a day.
- F. Avoid caffeine while experiencing diarrhea.
- G. Drink lots of fluids several times a day.
Correct Answer: B, C, F, G
Rationale: The correct instructions for the nurse to include are B, C, F, and G.
B: Probiotic foods like yogurt can help restore gut health.
C: Alcohol can worsen diarrhea, so it's important to avoid it.
F: Caffeine can be irritating to the digestive system, so avoiding it is beneficial.
G: Drinking lots of fluids helps prevent dehydration from diarrhea.
These instructions are essential for managing diarrhea effectively.
Incorrect options:
A: High-calcium foods may not be well-tolerated during diarrhea.
D: Raw vegetables can be difficult to digest during diarrhea.
E: Eating three large meals can be too much for a digestive system experiencing diarrhea.
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
- A. Check the client for injuries.
- B. Move hazardous objects away from the client.
- C. Notify the provider.
- D. Ask the client to describe how she felt prior to the fall.
Correct Answer: A
Rationale: The correct action is A: Check the client for injuries. This is the first priority to ensure the client's immediate safety and well-being. By assessing for injuries first, the nurse can determine the severity of the situation and provide appropriate care. Moving hazardous objects (B) can wait until the client's safety is ensured. Notifying the provider (C) can be done after assessing the client's condition. Asking the client to describe how she felt prior to the fall (D) is important but not as urgent as checking for injuries.
The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
- A. Wear an N95 mask when caring for the client.
- B. Place a container for soiled linens inside the client's room.
- C. Place the client in a negative airflow room.
- D. Remove mask after exiting the client's room.
- E. Wear a sterile water-resistant gown if within 3 feet of the client.
Correct Answer: A, B, C, E
Rationale: The correct interventions for placing a client on isolation precautions include A, B, C, and E. A) Wearing an N95 mask is crucial for airborne precautions. B) Placing a container for soiled linens inside the room prevents contamination. C) A negative airflow room helps contain airborne pathogens. E) Wearing a sterile water-resistant gown within close proximity to the client prevents transmission. D is incorrect as the mask should be removed inside the client's room. Choices F and G are likely blank options or not relevant to isolation precautions.
A nurse is talking with an older adult client who is contemplating retirement. The client states, 'I keep thinking about how much I enjoy my job. I'm not sure I want to retire.' Which of the following responses should the nurse make?
- A. You would have so much more time to spend with your family.'
- B. You should consider getting a part-time job or doing volunteer work.'
- C. Let's talk about how the change in your job status will affect you.'
- D. Why wouldn't you want to retire and relax?
Correct Answer: C
Rationale: The correct response is C: "Let's talk about how the change in your job status will affect you." This response shows empathy and understanding towards the client's concerns and opens up a dialogue to explore the client's feelings and thoughts about retirement. It allows the nurse to assess the client's emotional readiness and concerns, facilitating a supportive conversation.
Other choices are incorrect:
A: This response assumes that the client's main concern is spending time with family, which may not be the case.
B: While volunteering or working part-time are valid options, this response does not address the client's current feelings and may come across as dismissive.
D: This response is judgmental and does not acknowledge the client's perspective or concerns, potentially shutting down communication.