Nokea
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. WBC count
- B. BUN
- C. Potassium
Correct Answer: A
Rationale: The correct answer is A: WBC count. An elevation in WBC count indicates the presence of infection as the body releases more white blood cells to fight off pathogens. In the case of a pressure ulcer, an increased WBC count suggests bacterial invasion and inflammation at the site of the ulcer. BUN (choice B) and Potassium (choice C) are not specific indicators of infection and are more related to kidney function and electrolyte balance, respectively. Therefore, they are not appropriate for determining infection in this context.
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A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse’s initial action?
- A. Check the drainage for glucose.
- B. Notify the client’s provider.
- C. Document the amount of drainage.
- D. Obtain a culture of the drainage.
Correct Answer: A
Rationale: The correct initial action is to check the drainage for glucose (Choice A). This is crucial because clear drainage after a transsphenoidal hypophysectomy may indicate a cerebrospinal fluid leak, which can be confirmed by the presence of glucose in the drainage. If glucose is present, it suggests leakage of cerebrospinal fluid and requires immediate intervention to prevent complications such as infection and meningitis. The other options (B, C, and D) are not the most appropriate initial actions. Notifying the provider, documenting the amount of drainage, or obtaining a culture can be important steps but should come after confirming the presence of glucose to address the immediate concern of a potential cerebrospinal fluid leak.
A nurse is caring for a client whose family member requests to view the client’s medical record. Which of the following responses should the nurse make?
- A. The ethics committee will need to approve this request for you.
- B. I will ask the nursing supervisor to obtain the medical records for you.
- C. The healthcare provider will share this information with you.
- D. The client must provide permission to share the records with you.
Correct Answer: D
Rationale: The correct response is D: The client must provide permission to share the records with you. This is the correct answer because under HIPAA regulations, a client's medical records are confidential and can only be shared with the client's explicit permission. The nurse cannot disclose the records to a family member without the client's consent. Option A is incorrect because the ethics committee does not handle individual requests for medical records. Option B is incorrect as the nursing supervisor cannot release medical records without proper authorization. Option C is incorrect as the healthcare provider cannot share the information without the client's consent.
A nurse at a family practice clinic receives a call from a client who is prescribed oral contraceptives but forgot to take one dose. The client reports she is in the first week of a 28-day cycle pack. Which of the following instructions should the nurse provide?
- A. Stop taking the pills and switch to a different contraceptive method.
- B. Take a home pregnancy test.
- C. Do not have vaginal intercourse until after your next period.
- D. Take the missed dose now, then continue the medication as ordered.
Correct Answer: D
Rationale: The correct answer is D: Take the missed dose now, then continue the medication as ordered. In the first week of a 28-day cycle pack, missing one pill does not significantly impact contraceptive efficacy. Taking the missed dose as soon as possible and then continuing the medication as prescribed maintains the contraceptive effectiveness. Choice A is incorrect as stopping the pills abruptly can lead to unintended pregnancy. Choice B is unnecessary as missing one pill does not automatically indicate pregnancy. Choice C is not relevant in this context as the client can still take the missed dose and continue with the contraceptive method.
A nurse is providing discharge teaching to the parent of a child who is prescribed diphenhydramine 25 mg elixir every 4 hours as needed. The amount available is diphenhydramine elixir 12.5 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 2
Rationale: Correct Answer: 2 mL
Rationale: To calculate the mL per dose, divide the prescribed mg by the concentration in mg/mL. 25 mg ÷ 12.5 mg/mL = 2 mL. This dosage ensures the correct amount of diphenhydramine is administered.
Summary of Other Choices:
A: Incorrect, as it does not calculate the dosage correctly.
B-G: Irrelevant as they do not provide any calculations or rationale for the correct dosage.
A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching?
- A. Your largest meal of the day should be in the evening.
- B. Eating yogurt can help decrease the amount of gas that I have.
- C. Carbonated beverages can help control odor.
- D. I should eliminate pasta from my diet so that I don’t have many loose stools.
Correct Answer: B
Rationale: The correct answer is B because eating yogurt can help decrease gas due to its probiotic properties which aid in digestion. This statement shows the client understands dietary adjustments post-colostomy surgery. Choice A is incorrect as meal distribution does not affect colostomy care. Choice C is incorrect as carbonated beverages can worsen odor. Choice D is incorrect as pasta is not necessarily a problematic food post-colostomy.