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A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?
- A. Using a cuff that is too small will result in an inaccurately high reading.
- B. Using a cuff that is too large will result in an inaccurately low reading.
- C. The regular size cuff is appropriate for all clients.
- D. You should use a cuff of any size as long as it fits.
Correct Answer: A
Rationale: The correct answer is A: 'Using a cuff that is too small will result in an inaccurately high reading.' When obtaining blood pressure for an obese client, it is crucial to use a larger cuff to ensure an accurate reading. Choice B is incorrect because using a cuff that is too large for an obese client would actually result in an inaccurately low reading. Choice C is incorrect as a regular size cuff is not appropriate for obese clients due to their larger arm circumference. Choice D is incorrect because using a cuff of any size as long as it fits is not suitable for obtaining accurate blood pressure readings on an obese client.
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A client is receiving chemotherapy for breast cancer. Which laboratory value would be most important for the nurse to monitor?
- A. White blood cell count
- B. Hemoglobin level
- C. Serum creatinine
- D. Blood glucose level
Correct Answer: A
Rationale: The correct answer is to monitor the white blood cell count. Chemotherapy can lead to neutropenia, which is a decrease in white blood cells, particularly neutrophils. Neutropenia increases the risk of infections, making it crucial to monitor the white blood cell count during chemotherapy. Monitoring hemoglobin level is important but not as critical as white blood cell count in this scenario. Serum creatinine and blood glucose levels are not directly impacted by chemotherapy for breast cancer, making them less relevant to monitor in this situation.
A healthcare professional is admitting a client who has influenza. Which of the following types of transmission precautions should the healthcare professional initiate?
- A. Airborne
- B. Droplet
- C. Contact
- D. Protective environment
Correct Answer: B
Rationale: Droplet precautions should be initiated for clients with infections that spread via droplet nuclei larger than 5 microns in diameter, such as influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. In the case of influenza, the virus is primarily spread through respiratory droplets produced when an infected person coughs, sneezes, or talks. Airborne precautions are used for pathogens that remain infectious over long distances, typically smaller than 5 microns, like tuberculosis. Contact precautions are for diseases transmitted by direct or indirect contact, and protective environment precautions are for immunocompromised individuals to protect them from environmental pathogens.
The nurse is caring for a client with cirrhosis of the liver. Which finding should the LPN/LVN report to the healthcare provider immediately?
- A. Yellowing of the skin and eyes
- B. Dark-colored urine
- C. Abdominal distention
- D. Confusion
Correct Answer: A
Rationale: Yellowing of the skin and eyes (jaundice) is a classic sign of liver dysfunction in clients with cirrhosis. Jaundice indicates the accumulation of bilirubin in the body due to impaired liver function. This finding suggests worsening liver damage and should be reported immediately to the healthcare provider for prompt evaluation and management. Dark-colored urine (choice B) is also a concerning symptom in liver disease, indicating possible bilirubin presence, but it is not as urgent as jaundice. Abdominal distention (choice C) and confusion (choice D) are common in cirrhosis but do not indicate an immediate need for healthcare provider notification compared to jajsondice.
A client has a new prescription for a metered-dose inhaler. Which of the following instructions should the nurse include?
- A. Inhale quickly and deeply while pressing down on the inhaler.
- B. Hold your breath for 10 seconds after inhaling the medication.
- C. Exhale immediately after inhaling the medication.
- D. Shake the inhaler before each use.
Correct Answer: B
Rationale: The correct instruction for using a metered-dose inhaler is to hold your breath for 10 seconds after inhaling the medication. This allows the medication to be absorbed more effectively in the lungs. Inhaling quickly and deeply while pressing down on the inhaler (Choice A) may cause the medication to deposit in the mouth and throat rather than reaching the lungs. Exhaling immediately after inhaling the medication (Choice C) may also lead to medication wastage. Shaking the inhaler before each use (Choice D) is not necessary for all types of inhalers and can sometimes cause improper drug delivery.
Which nursing diagnosis would be a priority for a client admitted with a CVA (cerebral vascular accident)?
- A. Risk for aspiration
- B. Impaired physical mobility
- C. Disturbed sensory perception
- D. Interrupted family processes
Correct Answer: A
Rationale: The correct answer is 'Risk for aspiration' as it is a priority concern in clients with a CVA due to potential swallowing difficulties. Aspiration poses immediate risks such as pneumonia, which can be life-threatening. Impaired physical mobility, while important, may not be as urgent as the risk for aspiration in this scenario. Disturbed sensory perception and interrupted family processes are not typically the most critical concerns in the acute phase of a CVA.