Nokea
A nurse is reviewing the laboratory results of a client and notes a calcium level of 7.2 mg/dL. Which of the following findings should the nurse expect?
- A. Hypoactive deep-tendon reflexes
- B. Numbness of extremities
- C. Dry, sticky mucous membranes
- D. Decreased bowel sounds
Correct Answer: B
Rationale: The correct answer is B: Numbness of extremities. A calcium level of 7.2 mg/dL indicates hypocalcemia, which can lead to neuromuscular excitability and tingling sensations. Numbness of extremities is a common symptom of hypocalcemia due to its effect on nerve function. Hypoactive deep-tendon reflexes (choice A) are associated with hypercalcemia, not hypocalcemia. Dry, sticky mucous membranes (choice C) are more indicative of dehydration. Decreased bowel sounds (choice D) may be seen in conditions affecting the gastrointestinal tract, but are not directly related to calcium levels.
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A nurse is measuring an adult client's tympanic temperature. Which of the following actions should the nurse take?
- A. Use a cotton-tipped applicator to remove cerumen.
- B. Pull the pinna downward and backward.
- C. Aim the probe posteriorly in the direction of the eardrum.
- D. Insert the probe with a circular motion.
Correct Answer: C
Rationale: The correct answer is C because aiming the probe posteriorly in the direction of the eardrum allows for accurate tympanic temperature measurement. This ensures that the infrared sensor is positioned correctly to capture the heat emitted from the tympanic membrane. Choice A is incorrect as removing cerumen is not necessary for temperature measurement. Choice B is incorrect as pulling the pinna downward and backward is not required for tympanic temperature measurement. Choice D is incorrect as inserting the probe with a circular motion may cause discomfort or injury to the ear canal.
A newly licensed nurse has obtained a capillary glucose level from a client that produced inaccurate results and reports this to the charge nurse. Which of the following actions should the charge nurse take?
- A. Assign another nurse to be responsible for obtaining capillary glucose levels.
- B. Verify that the newly licensed nurse attended the staff education class about capillary glucose levels.
- C. Repeat the capillary glucose levels.
- D. Recheck the next scheduled capillary glucose level immediately following the nurse's.
Correct Answer: C
Rationale: The correct answer is C: Repeat the capillary glucose levels. This action should be taken to confirm the accuracy of the initial results. By repeating the test, the charge nurse can determine if the inaccuracy was due to a procedural error or if there is an issue with the equipment. This step ensures that the client receives proper care based on accurate information.
Assigning another nurse (choice A) does not address the root cause of the inaccurate results. Verifying attendance at an education class (choice B) is not as immediate or relevant as repeating the test. Rechecking the next scheduled level (choice D) without verifying the accuracy of the initial result may lead to continued inaccuracies in care.
A nurse is caring for a client who has hemophilia and has developed hemarthrosis of the left knee. Which of the following actions should the nurse take?
- A. Administer low-dose aspirin.
- B. Apply heat to the knee.
- C. Administer analgesics IM.
- D. Elevate the knee.
Correct Answer: D
Rationale: The correct answer is D: Elevate the knee. Elevating the knee helps reduce swelling and promote venous return, which can help alleviate pain and prevent further bleeding in hemarthrosis. Administering low-dose aspirin (A) is contraindicated in hemophilia as it can increase the risk of bleeding. Applying heat (B) can exacerbate bleeding by increasing blood flow to the area. Administering analgesics IM (C) may provide pain relief but does not address the underlying issue of bleeding.
A nurse in an extended-care facility is reinforcing teaching with a group of newly licensed nurses about the expected physiologic changes of aging. Which of the following information should the nurse include? (Select all that apply.)
- A. More difficulty seeing due to a greater sensitivity to glare
- B. Decreased cough reflex
- C. Decreased bladder capacity
- D. Decreased systolic blood pressure
- E. Dehydration of intervertebral discs
Correct Answer: A,B,C,E
Rationale: Correct Answer: A, B, C, E
Rationale:
A: With aging, the lens of the eye becomes less flexible, leading to difficulty seeing due to glare.
B: Aging affects the cough reflex, making it less effective in clearing the respiratory tract.
C: Bladder capacity decreases with age due to decreased muscle tone and elasticity.
E: Intervertebral discs lose water content with age, leading to dehydration and decreased flexibility.
Incorrect Choices:
D: Systolic blood pressure tends to increase with age, not decrease.
F, G: No information provided to analyze these options.
A nurse is caring for a client who says, 'I'm feeling a bit nervous today.' Which of the following responses should the nurse make?
- A. Please explain what you mean by nervous.
- B. Why are you nervous?
- C. Would a backrub ease your nervousness?
- D. You look like you feel nervous.
Correct Answer: A
Rationale: Seeking clarification helps the nurse understand the client's feelings more accurately.