Nokea
A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient?
- A. Hypostatic pneumonia
- B. Renal calculi
- C. Pressure ulcers
- D. Thrombus formation
Correct Answer: B
Rationale: The correct answer is B: Renal calculi. Hypercalcemia can lead to the formation of kidney stones (renal calculi) due to increased levels of calcium in the blood being excreted by the kidneys. The nurse should monitor for signs and symptoms of renal colic, such as severe flank pain, hematuria, and urinary urgency.
Incorrect choices:
A: Hypostatic pneumonia - Hypercalcemia does not directly lead to pneumonia.
C: Pressure ulcers - Hypercalcemia does not increase the risk of pressure ulcers.
D: Thrombus formation - While hypercalcemia can predispose to blood clot formation, it is not the most closely monitored condition in this scenario.
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Nurse contributing to care plan for client being admitted to facility with suspected dx of pertussis. Which should nurse include in care plan?
- A. Place client in room with negative air pressure of at least 6 exchanges per hour
- B. Wear mask when providing care within 3 ft of client
- C. Place mask on client if transportation to another dept is unavoidable
- D. Use sterile gloves when handling soiled linens
- E. Wear gown when performing care that may result in contamination from secretions
Correct Answer: B,C,E
Rationale: The correct answer includes wearing a mask when providing care within 3 feet of the client to prevent the spread of pertussis through respiratory droplets. Placing a mask on the client during unavoidable transportation helps reduce exposure to others. Wearing a gown when performing care that may result in contamination from secretions is essential to prevent transmission through contact. Choice A is incorrect because negative air pressure is not necessary for pertussis isolation. Choice D is unnecessary as pertussis is not transmitted through contact with soiled linens.
A home health nurse is discussing dangers of carbon monoxide poisoning with a client. What information should the nurse include?
- A. Carbon monoxide has a distinct odor
- B. Water heaters should be inspected every 5 years
- C. Lungs are damaged from carbon monoxide inhalation
- D. Carbon monoxide binds with hemoglobin in body
Correct Answer: D
Rationale: The correct answer is D: Carbon monoxide binds with hemoglobin in the body. This is correct because carbon monoxide binds with hemoglobin in the blood more easily than oxygen, leading to decreased oxygen delivery to tissues. This can result in symptoms of carbon monoxide poisoning.
A: Carbon monoxide is odorless, so this is incorrect.
B: While regular inspection of appliances like water heaters is important for safety, it is not directly related to carbon monoxide poisoning.
C: Carbon monoxide primarily affects the body by interfering with oxygen transport, not by directly damaging the lungs.
In summary, choice D is correct because it explains the mechanism of carbon monoxide poisoning, while the other choices are incorrect as they do not directly relate to the dangers of carbon monoxide poisoning.
Nurse talking with parents of 6 mo infant about gross motor development. Which gross motor skills are expected in next 3 mo? (Select all that apply.)
- A. Rolls from back to front
- B. Bears weight on legs
- C. Walks holding onto furniture
- D. Sits unsupported
- E. Sits down from standing position
Correct Answer: A,B,D
Rationale: The correct answers are A, B, and D. In the next 3 months, the infant is expected to roll from back to front (A), bear weight on legs (B), and sit unsupported (D). Rolling develops around 4-6 months, weight-bearing on legs around 6-9 months, and sitting unsupported around 6-8 months. Choice C, walking holding onto furniture, is more characteristic of the 9-12 month age range. Choice E, sitting down from a standing position, typically occurs after the infant has mastered standing independently, which is beyond the 9-month mark.
Mother of 7 mo infant tells nurse that her baby has been fussy with occasional loose stools since she started feeding him fruits & veggies. Which responses by nurse are appropriate? (Select all that apply.)
- A. It might be good to add bananas, as they help with loose stools
- B. Let's make list of foods he's eating so we can spot problems
- C. Did the changes begin after you started 1 particular food?
- D. Has he been vomiting since he started these new foods?
- E. Most babies react with indigestion when you start new foods
Correct Answer: B,C,D
Rationale: Correct Answer: B, C, D
Rationale:
B: Making a list of foods eaten helps identify potential triggers for fussiness and loose stools.
C: Asking about a specific food can pinpoint the culprit causing the symptoms.
D: Vomiting could indicate a more serious issue, so this question helps assess the severity of the symptoms.
Incorrect Choices:
A: Bananas may not necessarily help with loose stools, and adding more foods could worsen the issue.
E: Making a generalization about how babies react to new foods is not helpful in this specific case.
An RN is making assignments for client care to an LPN at the beginning of shift. Which of the following assignments should the LPN question?
- A. Assisting a client who is 24h post-op to use incentive spirometer
- B. Collecting clean-catch urine specimen
- C. Providing nasopharyngeal suctioning for pneumonia client
- D. Replacing cartridge & tubing on PCA pump
Correct Answer: D
Rationale: The LPN should question replacing cartridge & tubing on PCA pump (Choice D) because this task involves manipulating the patient's medication delivery system, which is beyond the LPN's scope of practice. LPNs are not trained to handle complex medication administration devices like PCA pumps, as this requires a higher level of knowledge and skill typically reserved for RNs. The LPN should advocate for clarification from the RN or delegate this task to someone with the appropriate training. Choices A, B, and C are within the LPN's scope of practice and do not require specialized training like manipulating a PCA pump.