Nokea
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 caring for a client who has a herniated disc and is scheduled for a peripheral nerve block. The client tells the nurse, 'I am afraid to have this procedure.' Which of the following responses should the nurse make?
- A. Are you afraid of needles that will be used during the procedure?'
- B. After this procedure, you will feel much better.'
- C. Tell me why you are scared to have this procedure.'
- D. Let's discuss your concerns about this procedure.'
Correct Answer: D
Rationale: Rationale: Option D is correct as it acknowledges the client's fear and opens the door for a discussion about their concerns, allowing the nurse to address them. It shows empathy and promotes client-centered care. Option A focuses solely on needles, which may not address the client's overall fear. Option B dismisses the client's feelings without addressing their fear. Option C asks for the reason but may not actively engage in addressing the fear. Overall, option D is the best choice as it demonstrates active listening and a willingness to address the client's specific concerns.
A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output?
- A. Weight gain
- B. Distended abdomen
- C. Confusion
- D. Dyspnea
Correct Answer: C
Rationale: The correct answer is C: Confusion. In left-sided heart failure, decreased cardiac output can lead to decreased perfusion to the brain, resulting in confusion. Weight gain (A) is more indicative of fluid retention, distended abdomen (B) is a sign of ascites or abdominal organ enlargement, and dyspnea (D) is a common symptom of heart failure but not a direct indicator of decreased cardiac output.
A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?
- A. Administer antihypertensive medications.
- B. Maintain the client on NPO status.
- C. Place the client in a supine position.
- D. Monitor the client for hypercalcemia.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on NPO status. In acute pancreatitis, the pancreas is inflamed, leading to digestive enzyme release and potential autodigestion of pancreatic tissue. Keeping the client NPO (nothing by mouth) helps rest the pancreas by reducing stimulation of enzyme secretion. This allows the pancreas to heal and decreases the risk of further complications. Administering antihypertensive medications (A) is not typically a priority for acute pancreatitis. Placing the client in a supine position (C) may not directly impact the pancreatitis. Monitoring for hypercalcemia (D) is important in chronic pancreatitis but not typically a primary intervention in the acute phase.
A nurse is caring for a client receiving TPN. Which of the following actions should the nurse take?
- A. Monitor serum blood glucose during infusion.
- B. Obtain the client's weight daily.
- C. Infuse 0.9% sodium chloride if the solution is not available.
- D. Verify the solution with another RN prior to infusion.
Correct Answer: A
Rationale: The correct answer is A: Monitor serum blood glucose during infusion. This is crucial because TPN (total parenteral nutrition) is a high concentration of glucose and can lead to hyperglycemia. Regular monitoring helps in detecting and managing any glucose fluctuations promptly. Choice B is incorrect as daily weight is essential but not the priority when compared to monitoring glucose. Choice C is incorrect as infusing 0.9% sodium chloride as an alternative can lead to incompatible solutions and cause harm. Choice D is incorrect because verifying the solution with another RN is important for safety but does not address the immediate need for glucose monitoring.
A nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. Which of the following instructions should the nurse include?
- A. Limit fluids to 1.5 L per day.
- B. Avoid extremely hot or cold temperatures.
- C. Avoid getting a flu vaccination.
- D. Limit alcohol intake to one drink per day.
Correct Answer: B
Rationale: The correct answer is B: Avoid extremely hot or cold temperatures. This instruction is crucial for a client recovering from a sickle cell crisis as extreme temperatures can trigger or worsen a sickle cell crisis. Hot temperatures can lead to dehydration and increase the risk of vaso-occlusive events, while cold temperatures can cause vasoconstriction, leading to further sickling of red blood cells. Limiting fluids (A) is incorrect as hydration is important to prevent complications. Avoiding a flu vaccination (C) is also incorrect as it is recommended to protect against infections that can trigger a crisis. Limiting alcohol intake (D) is not directly related to sickle cell crisis recovery.