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A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results?
- A. Chloride level
- B. Creatinine kinase
- C. Uric acid
- D. Intrinsic factor
Correct Answer: C
Rationale: The correct answer is C: Uric acid. In acute gout, there is an increase in uric acid levels due to the deposition of urate crystals in the joints, causing inflammation and pain. Elevated uric acid levels are a hallmark of gout.
A: Chloride level is not directly related to acute gout.
B: Creatinine kinase is a marker of muscle damage, not specific to gout.
D: Intrinsic factor is related to vitamin B12 absorption, not gout.
Therefore, the nurse should expect an increase in uric acid levels as the most appropriate laboratory result in a client with acute gout.
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A nurse is planning to withdraw medication from an ampule to prepare for an injection. Which of the following actions should the nurse plan to take?
- A. Withdraw the medication from the ampule using a needleless system.
- B. Place a paper towel around the ampule's neck to break off the top with both hands.
- C. Dispose of the top of the ampule in a sharps container.
- D. Expel air into the ampule to aspirate air bubbles.
Correct Answer: B
Rationale: The correct answer is B: Place a paper towel around the ampule's neck to break off the top with both hands. This method helps prevent injury as the paper towel provides grip and protection. Breaking the ampule's top with both hands reduces the risk of glass shards. Using a needleless system (A) is not necessary for breaking an ampule. Disposing the top in a sharps container (C) is important, but it is not the immediate action for withdrawing medication. Expelling air into the ampule (D) is unnecessary and may introduce air bubbles into the medication.
A nurse is continuing to care for a client who is postoperative following surgical removal of an abdominal abscess. Which of the following actions should the nurse take?
- A. Obtain vital signs every 30 minutes.
- B. Elevate the client in a semi-Fowler's position.
- C. Apply oxygen.
- D. Monitor the client's level of consciousness.
Correct Answer: B
Rationale: The correct answer is B: Elevate the client in a semi-Fowler's position. Elevating the client in a semi-Fowler's position helps promote optimal lung expansion and ventilation, reducing the risk of postoperative complications such as atelectasis and pneumonia. This position also aids in preventing aspiration and promotes comfort.
Choice A: Obtaining vital signs every 30 minutes is important postoperatively, but it is not the most immediate action needed in this case.
Choice C: Applying oxygen may be necessary depending on the client's oxygen saturation levels, but it is not the most essential action to take at this point.
Choice D: Monitoring the client's level of consciousness is important, but it is not as critical as positioning the client correctly to prevent respiratory complications.
A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will draw up the regular insulin into the syringe first.
- B. I will shake the NPH vial vigorously before drawing up the insulin.
- C. I will store prefilled syringes in the refrigerator with the needle pointed downward.
- D. I will insert the needle at a 15-degree angle.
Correct Answer: A
Rationale: Correct Answer: A - "I will draw up the regular insulin into the syringe first."
Rationale: Drawing up regular insulin before NPH prevents contamination. Regular insulin has a clear appearance, making it easier to detect any contamination. Drawing up NPH first can cause regular insulin to be contaminated if the same syringe is used. This statement demonstrates an understanding of the importance of preventing contamination and following proper insulin administration technique.
Summary of Incorrect Choices:
B: Shaking the NPH vial vigorously can cause air bubbles, affecting the accuracy of the dose.
C: Storing prefilled syringes in the refrigerator with the needle downward can cause leakage or contamination.
D: Inserting the needle at a 15-degree angle may not be appropriate for insulin injection, which typically requires a 90-degree angle for subcutaneous administration.
A nurse is caring for a client who has heart failure. Which of the following findings indicate the client is at risk for developing complications?
- A. Dysrhythmias
- B. Respiratory alkalosis
- C. Acute kidney injury
- D. Fluid volume deficit
Correct Answer: A
Rationale: The correct answer is A, dysrhythmias. In heart failure, the heart's inability to pump effectively can lead to electrical disturbances causing dysrhythmias, which can be life-threatening. Dysrhythmias can result in decreased cardiac output, further exacerbating heart failure. Respiratory alkalosis (B) is not a direct complication of heart failure. Acute kidney injury (C) can occur due to decreased cardiac output, leading to decreased renal perfusion, but it is not a direct risk factor for complications in heart failure. Fluid volume deficit (D) is a common finding in heart failure due to fluid retention, but it is not a direct risk for complications like dysrhythmias.
A nurse is caring for a client who is receiving morphine through a PCA device. Which of the following actions should the nurse take?
- A. Teach the client how to self-medicate using the PCA device.
- B. Encourage family members to press the PCA button for the client.
- C. Monitor the client's respiratory status every 4 hr.
- D. Administer an oral opioid for breakthrough pain.
Correct Answer: A
Rationale: The correct answer is A: Teach the client how to self-medicate using the PCA device. This is important because it empowers the client to control their pain management while ensuring safety. Teaching the client how to use the PCA device helps promote autonomy and ensures that the client is receiving the appropriate dose of medication as prescribed. Encouraging family members to press the button (B) may lead to inappropriate dosing and compromise the client's safety. Monitoring respiratory status (C) is important but should be done more frequently, such as every hour, as respiratory depression can occur with morphine use. Administering an oral opioid for breakthrough pain (D) may not be necessary if the client is able to self-medicate effectively with the PCA device.