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A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?
- A. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL)
- B. Aspartate aminotransferase 34 units/L (0 to 34 units/L)
- C. Ammonia 55 mcg/dL (10 to 80 mcg/dL)
- D. Platelets 60,000/mm3 (150,000 to 400,000/mm3)
Correct Answer: D
Rationale: A platelet count of 60,000/mm3 is significantly below the normal range and increases the risk of bleeding during a liver biopsy, so it should be reported. The other values are within normal limits and do not pose an immediate concern.
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A home health nurse is assisting in the care of a client following a modified radical mastectomy. Which of the following statements by the client indicates effective coping?
- A. I would like to see what this looks like today.
- B. I would just like to spend my day staring at the TV.
- C. I'm going to close my eyes until you are done dressing my incision.
- D. I'm planning to stay at home until my breast reconstructive surgery.
- E. I don't care about my appearance anymore.
- F. I'll never leave the house again.
- G. I feel fine and don't need help.
Correct Answer: A
Rationale: Wanting to see the incision shows acceptance and engagement in recovery; other options suggest avoidance or denial.
A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow.
- A. Empty the urine into a sterile container labeled with the client identifiers.
- B. Document in the client's electronic medical record that the specimen was sent to the laboratory.
- C. Attach a sterile needleless syringe to the sample port and aspirate the specimen.
- D. Wipe the sample port with an alcohol wipe and let the alcohol dry.
- E. Clamp the catheter tubing distal to the sampling port for 15 min.
Correct Answer: E,D,C,A,B
Rationale: Order: Clamp (E), wipe port (D), aspirate (C), transfer (A), document (B) ensures sterility and proper procedure.
A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion?
- A. Distended neck veins
- B. Polyuria
- C. Vomiting
- D. Hypertension
- E. Fever and chills
- F. Tachycardia
- G. Hypotension
Correct Answer: C
Rationale: Vomiting is a sign of a septic reaction due to contaminated blood; distended veins suggest fluid overload, polyuria isn't typical, and hypertension isn't specific.
Medication Administration Record
Ceftriaxone 2 gm IV BID
Acetaminophen 325 mg PO every 4 hr PRN fever over 39° C (102.2° F)
Guaifenesin 200 mg PO every 4 hr PRN cough
Diagnostic Results
Complete Blood Count:
Hemoglobin 15 g/dL (12 to 16 g/dL)
Hematocrit 45% (37% to 47%)
WBC count 15,000/mm* (5000 to 10,000/mm*)
Basic Metabolic Profile:
Creatinine 2.8 mg/dL (0.5 to 1.1 mg/di)
BUN 19 mg/dL (10 to 20 mg/dL)
Sputum Culture and Sensitivity:
Klebsiella pneumonia
A nurse is reviewing the medical record of a client who has pneumonia. Which of the following information is the priority for the nurse report to the provider?
- A. Sputum results
- B. Creatinine level
- C. Temperature
- D. WBC count
- E. Oxygen saturation
- F. Blood pressure
- G. Respiratory rate
Correct Answer: B
Rationale: Elevated creatinine (2.8 mg/dL) indicates potential kidney injury, a priority over sputum (expected Klebsiella), WBC (infection), or temperature.
Vital Signs
1000:
Temperature 37° C (98.6° F)
Blood pressure 132/60 mm Hg right arm supine
Blood pressure 118/60 mm Hg right arm sitting
Blood pressure 102/50 mm Hg right arm standing
Heart rate 108/min
Respiratory rate 24/min
Pulse oximetry 94% on room air
History and Physical
1000:
Client reports generalized weakness and increased fatigue over the past few months.
Client states they become short of breath after climbing a flight of stairs and are having difficulty keeping up with their grandchildren.
History of rheumatoid arthritis. Reports taking naproxen 500 mg twice a day.
Client reports they follow a vegan diet.
Denies pain or discomfort.
Bilateral breath sounds clear and present throughout.
Mucous membranes pale.
Apical pulse rapid, regular.
Nurses' Notes
1100:
Reinforced education about iron supplements and dietary recommendations.
Which of the following 3 statements indicate the client understands the instructions? (Iron deficiency anemia)
- A. I should increase green leafy vegetables in my diet
- B. The iron supplement might cause my stools to be black.
- C. I should expect to have swelling in my feet.
- D. I will take my iron supplement 1 hour before a meal.
- E. The iron supplement might cause ringing in my ears.
- F. I'll take it with milk for better absorption.
- G. I should avoid citrus fruits.
Correct Answer: A,B,D
Rationale: Green leafy vegetables provide iron, black stools are a side effect, and taking it before meals enhances absorption.