Nokea
A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?
- A. The client consumed citrus juice 3 days before the test.
- B. The client takes ibuprofen for headaches.
- C. The client had a hemorrhoidectomy 1 year ago.
- D. The client has a history of breast cancer.
Correct Answer: B
Rationale: Fecal occult blood tests detect hidden blood in stool, often for colorectal cancer screening, but false positives can skew results. Ibuprofen, an NSAID, irritates the gastric mucosa, causing microbleeding that may appear in stool, unrelated to colonic sources. Citrus juice doesn't affect heme detection vitamin C may cause false negatives, not positives, and 3 days prior minimizes impact. A hemorrhoidectomy 1 year ago is healed, unlikely to bleed now unless complications persist, which isn't suggested. Breast cancer history doesn't influence gastrointestinal bleeding unless metastatic, an unlikely scenario here. Ibuprofen's known GI side effects align with testing guidelines (e.g., avoiding NSAIDs pre-test), making it the most likely false-positive trigger, requiring the nurse to clarify timing and adjust interpretation.
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Vital Signs
1000:
Temperature 37° C (98.6° F)
Blood pressure 132/60 mm Hg right arm supine
Blood pressure 118/60 mm Hg right arm sitting
Blood pressure 102/50 mm Hg right arm standing
Heart rate 108/min
Respiratory rate 24/min
Pulse oximetry 94% on room air
Nurses Notes
1100:
Reinforced education about iron supplements and dietary recommendations.
Which of the following instructions should the nurse include? (Client with iron deficiency anemia)
- A. Take an antacid within 30 min after medication
- B. Increase sources of fiber in the diet.
- C. Take the medication with a source of vitamin C
- D. Take the medication on an empty stomach.
- E. Increase intake of milk and dairy products.
- F. Expect immediate energy improvement.
- G. Avoid green leafy vegetables.
Correct Answer: B,C,D
Rationale: Fiber prevents constipation, vitamin C enhances absorption, and empty stomach improves uptake; antacids and dairy reduce absorption.
A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?
- A. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL)
- B. Ammonia 55 mcg/dL (10 to 80 mcg/dL)
- C. Aspartate aminotransferase 34 units/L (0 to 34 units/L)
- D. Platelets 60,000/mm³ (150,000 to 400,000/mm³)
Correct Answer: D
Rationale: Liver biopsy carries bleeding risk due to the organ's vascularity, so clotting ability is critical. Platelets at 60,000/mm³ are severely low (normal 150,000-400,000/mm³), increasing hemorrhage risk post-procedure. Bilirubin (1.0 mg/dL) and AST (34 units/L) are within normal limits, reflecting liver function but not bleeding tendency. Ammonia (55 mcg/dL) is normal, relevant to encephalopathy, not biopsy safety. Thrombocytopenia below 100,000/mm³ often prompts transfusion or delay per procedural protocols, as platelets are vital for hemostasis. Reporting this to the provider ensures risk assessment potentially canceling or modifying the biopsy prioritizing patient safety over proceeding with normal liver markers, making it the critical value to escalate.
A nurse in a long-term care facility is assisting with the plan of care for a client who has late-stage Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Turn the client every 2 hr to prevent pressure ulcers.
- B. Place a mirror in the client's room for reality orientation.
- C. Offer the client written instructions for performing oral hygiene.
- D. Ask the client open-ended questions to encourage conversation.
Correct Answer: A
Rationale: Late-stage Alzheimer's reduces mobility, heightening pressure ulcer risk. Turning every 2 hours redistributes weight, preserving skin integrity, a preventive standard (e.g., NPUAP guidelines). Mirrors confuse patients unable to recognize themselves, increasing agitation. Written instructions are futile severe cognitive loss prevents comprehension; physical cues work better. Open-ended questions overwhelm, as verbal ability is minimal; simple prompts suit better. Repositioning addresses a physical priority, reduces complications like infection, and upholds care quality, making it the essential action.
A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?
- A. Elevate the head of the client's bed for 1 hr. after the feeding.
- B. Administer the feeding solution at a cold temperature.
- C. Rotate the jejunostomy tube once per day.
- D. Flush the tube with 90 mL of sterile water before and after the feeding.
Correct Answer: A
Rationale: Elevating the head for 1 hour post-feeding prevents aspiration, a key concern with jejunostomy feedings. Cold solutions, rotation, and excessive flushing aren't standard.
A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?
- A. Replace the unit when the drainage chamber is full.
- B. Monitor for at least 150 mL of drainage every hour.
- C. Clamp the tube for 30 min every 8 hr.
- D. Pin the tubing to the client's bed sheets.
Correct Answer: A
Rationale: Chest tube systems remove pleural air or fluid, requiring functionality. Replacing the unit when full prevents backpressure or overflow, maintaining drainage and lung re-expansion, per manufacturer and infection control standards (e.g., CDC). Monitoring 150 mL/hr is excessive sudden high output signals hemorrhage, not routine care. Clamping risks tension pneumothorax by trapping air/fluid, only done briefly for specific checks (e.g., air leak). Pinning tubing prevents dislodgement, but full chamber replacement is the proactive maintenance action. This ensures system efficacy, prevents complications like atelectasis, and aligns with respiratory care priorities, making it the nurse's key responsibility.