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. 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.
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A nurse is providing teaching to a client about the manifestations of uterine prolapse. Which of the following statements by the client should indicate to the nurse a need for further teaching?
- A. I should avoid heavy lifting.
- B. Feces can be present in the vagina.
- C. I might experience urinary incontinence.
- D. Pelvic pressure may occur during intercourse.
Correct Answer: B
Rationale: The correct answer is B. Feces present in the vagina is not a manifestation of uterine prolapse; it is a symptom of rectocele. The other choices are correct for uterine prolapse: A - Heavy lifting can worsen prolapse, C - Urinary incontinence is common due to pelvic floor weakness, D - Pelvic pressure during intercourse is a symptom. Therefore, the client mentioning feces in the vagina indicates a need for further teaching on distinguishing between uterine prolapse and rectocele symptoms.
A nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis?
- A. Thyroid hormones
- B. Antihypertensives
- C. Steroids
- D. Insulin
Correct Answer: C
Rationale: The correct answer is C: Steroids. Steroids, specifically glucocorticoids, are known to increase the risk of osteoporosis by decreasing bone formation and increasing bone resorption. Long-term use of steroids can lead to bone loss, making individuals more susceptible to fractures. Thyroid hormones (A) do not directly cause osteoporosis. Antihypertensives (B) and insulin (D) are not associated with increased risk of osteoporosis.
A nurse is caring for a client who is 2 hours postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication?
- A. Output of dark amber urine
- B. Output of clear, light pink urine
- C. Output of bright red urine
- D. Output of burgundy colored urine
Correct Answer: D
Rationale: The correct answer is D: Output of burgundy colored urine. This indicates possible hemorrhage, a serious complication post-TURP. Dark amber urine (A) may suggest dehydration. Clear, light pink urine (B) is expected due to bladder irrigation post-TURP. Bright red urine (C) is common initially but should decrease over time. Burgundy colored urine (D) indicates active bleeding and requires immediate intervention.
A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include?
- A. It is primarily transmitted through direct contact with infected body fluids.
- B. It is transmitted through casual contact.
- C. It is transmitted through airborne droplets.
- D. It is only transmitted through sexual contact.
Correct Answer: A
Rationale: The correct answer is A because HIV is primarily transmitted through direct contact with infected body fluids such as blood, semen, vaginal fluids, and breast milk. This includes activities like unprotected sexual intercourse, sharing needles, and mother-to-child transmission during childbirth or breastfeeding. Casual contact (choice B) is not a common mode of transmission, and HIV is not transmitted through airborne droplets (choice C). While sexual contact is a significant mode of transmission, HIV can also be transmitted through other means involving infected body fluids. Thus, option D is incorrect as it is too limiting.
A nurse is caring for a client who has advanced lung cancer. The client's provider has recommended hospice services for the client. Which of the following statements by the client indicates a correct understanding of hospice care?
- A. I should expect the hospice team to help me manage my dyspnea.
- B. I will receive chemotherapy to treat my cancer.
- C. I will be admitted to the hospital for further treatment.
- D. I will receive radiation therapy to shrink the tumor.
Correct Answer: A
Rationale: Correct Answer: A - "I should expect the hospice team to help me manage my dyspnea."
Rationale: Hospice care focuses on providing comfort and quality of life for patients with terminal illnesses, such as advanced lung cancer. Dyspnea (difficulty breathing) is a common symptom in lung cancer patients, and the hospice team is trained to provide symptom management and relief. By acknowledging the role of the hospice team in managing dyspnea, the client demonstrates an understanding of the palliative nature of hospice care.
Summary of other choices:
B: "I will receive chemotherapy to treat my cancer." - Hospice care does not aim to cure the underlying illness but rather focuses on comfort and quality of life.
C: "I will be admitted to the hospital for further treatment." - Hospice care is typically provided in the comfort of the patient's own home or a hospice facility, not in a hospital setting for further treatment.
D: "I will receive radiation therapy