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A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function?
- A. Serum creatinine
- B. Serum potassium
- C. White blood cell count
- D. Hemoglobin level
Correct Answer: A
Rationale: The correct answer is A: Serum creatinine. Creatinine is a waste product produced by muscles and filtered out by the kidneys. In clients with SLE, renal involvement is common. Elevated serum creatinine levels indicate impaired renal function, as the kidneys are not effectively filtering out waste products. Monitoring serum creatinine levels helps assess renal function and detect kidney damage early.
Choices B, C, D, and E are incorrect as they do not directly reflect renal function. Serum potassium levels (B) are more indicative of electrolyte balance, white blood cell count (C) indicates immune response, and hemoglobin level (D) reflects oxygen-carrying capacity.
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A nurse assesses a client 2 hours after TURP. What indicates a complication?
- A. Clear urine output
- B. Burgundy-colored urine output
- C. Mild pain at the incision site
- D. Temperature of 98.6°F
Correct Answer: B
Rationale: The correct answer is B: Burgundy-colored urine output. This indicates a complication post-TURP due to potential bleeding. Clear urine output (A) is normal. Mild pain at the incision site (C) is expected. Temperature of 98.6°F (D) is within normal range.
A nurse is planning care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?
- A. Limit the number of health care workers entering the room.
- B. Encourage the client to engage in social activities.
- C. Ensure the client receives a flu vaccine during chemotherapy.
- D. Provide daily fresh fruits and vegetables.
Correct Answer: A
Rationale: The correct answer is A: Limit the number of health care workers entering the room. This is important because immunosuppressed clients are at higher risk for infections. By limiting the number of health care workers entering the room, the nurse can reduce the client's exposure to potential pathogens. This helps to maintain a clean and controlled environment for the client, decreasing the risk of acquiring infections.
Choice B is incorrect because social activities may expose the client to a higher risk of infections from others. Choice C is incorrect because administering a flu vaccine during chemotherapy may not be effective due to the client's compromised immune system. Choice D is incorrect as providing fresh fruits and vegetables does not directly address the risk of infections from health care workers.
A nurse is caring for a postoperative client. Which procedure places the client at highest risk for DVT?
- A. Appendectomy
- B. Hip arthroplasty
- C. Cholecystectomy
- D. Tonsillectomy
Correct Answer: B
Rationale: The correct answer is B: Hip arthroplasty. This procedure involves prolonged immobility, causing blood stasis and increasing the risk of deep vein thrombosis (DVT). The reduced blood flow in the legs can lead to clot formation. Appendectomy (A), cholecystectomy (C), and tonsillectomy (D) are not typically associated with prolonged immobility like hip arthroplasty, thus lower DVT risk.
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
- A. Serum albumin level
- B. WBC count
- C. Serum potassium level
- D. BUN
Correct Answer: B
Rationale: The correct answer is B: WBC count. An elevation in WBC count indicates an immune response to infection, as white blood cells increase to fight off pathogens. In the context of a pressure ulcer, an elevated WBC count suggests the presence of infection due to the body's response to foreign organisms. Other choices are not directly related to infection in this scenario. Serum albumin level (A) reflects nutritional status, serum potassium level (C) indicates electrolyte balance, and BUN (D) reflects kidney function. Hence, they are not specific indicators of infection in a client with a pressure ulcer.
A nurse is instructing a client how to decrease the nausea associated with chemotherapy and radiation. Which of the following statements indicates an understanding of the teaching?
- A. I will eat food that are served at room temperature.
- B. I will avoid drinking liquids with meals.
- C. I will eat spicy foods to improve appetite.
- D. I will drink hot liquids to settle my stomach.
Correct Answer: A
Rationale: The correct answer is A: "I will eat food that are served at room temperature." This is correct because consuming foods at room temperature helps reduce nausea associated with chemotherapy and radiation. Cold foods can worsen nausea, while hot foods can trigger vomiting. Avoiding extreme temperatures can help alleviate nausea.
Choice B is incorrect because avoiding liquids with meals can lead to dehydration and worsen nausea. Choice C is incorrect because spicy foods can exacerbate nausea rather than improve appetite. Choice D is incorrect because drinking hot liquids can aggravate nausea.