Nokea
A physician orders a serum creatinine for a hospitalized client. The nurse should explain to the client and his family that this test:
- A. is normal if the level is 4.0 to 5.5 mg/dl.
- B. can be elevated with increased protein intake.
- C. is a better indicator of renal function than the BUN.
- D. reflects the fluid volume status of a person
Correct Answer: C
Rationale: A serum creatinine level should be 0.7 to 1.5 mg/dl, and it does not vary with increased protein intake, so it is a better indicator of renal function than the BUN. Choice A is incorrect as a serum creatinine level of 4.0 to 5.5 mg/dl is not normal. Choice B is incorrect as serum creatinine is not affected by increased protein intake. Choice D is incorrect as serum creatinine primarily reflects renal function, not fluid volume status.
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The client diagnosed with end-stage liver disease has completed an advance directive and a do-not-resuscitate (DNR) document and wishes to receive palliative care. Which of the following would correspond to the client's wish for comfort care?
- A. Positioning frequently to prevent skin breakdown and providing pain management and other comfort measures
- B. Carrying out vigorous resuscitation efforts if the client were to stop breathing, but no resuscitation if the heart stops beating
- C. Providing intravenous fluids when the client becomes dehydrated
- D. Providing total parenteral nutrition (TPN) if the client is not able to eat
Correct Answer: A
Rationale: Palliative care includes measures to prevent skin breakdown, pain management, and management of other symptoms that cause discomfort, as well as encouraging contact with family and friends. A DNR request precludes all resuscitative efforts related to respiratory or cardiac arrest, making choice B incorrect. Dehydration is a natural part of the dying process, so providing intravenous fluids as in choice C would not align with the client's wish for comfort care. Total parenteral nutrition (TPN) as in choice D is an invasive procedure meant to prolong life and is not part of palliative care, which focuses on improving quality of life rather than extending it.
Which of the following microorganisms is easily transmitted from client to client on the hands of healthcare workers?
- A. mycobacterium tuberculosis
- B. clostridium tetani
- C. staphylococcus aureus
- D. human immunodeficiency virus
Correct Answer: C
Rationale: The correct answer is staphylococcus aureus. Staphylococcus aureus microorganisms are ubiquitous and easily transmitted by healthcare workers who fail to conduct routine hand washing between clients. Staphylococcus aureus can reside on the skin and be transferred from one client to another if proper hand hygiene is not practiced. Mycobacterium tuberculosis is mainly transmitted through the airborne route, clostridium tetani is usually acquired through exposure to soil or dirt contaminated with tetanus spores, and human immunodeficiency virus is not easily transmitted through casual contact or on the hands of healthcare workers.
When assessing a client in the Emergency Department whose membranes have ruptured, the nurse notes that the fluid is a greenish color. What is the cause of this greenish coloration?
- A. blood
- B. meconium
- C. hydramnios
- D. caput
Correct Answer: B
Rationale: The correct answer is B: meconium. Greenish amniotic fluid passed when the fetus is in a cephalic (head) presentation might indicate fetal distress. A fetus in the breech presentation passes meconium due to compression on the intestinal tract. Choice A, blood, is incorrect as blood in the amniotic fluid would present as a different color. Choice C, hydramnios, refers to an excess of amniotic fluid and would not cause the greenish coloration. Choice D, caput, is swelling of a newborn's scalp and is not related to the color of the amniotic fluid.
What are the side effects of first-generation over-the-counter (OTC) antihistamines like diphenhydramine (Benadryl) and hydroxyzine (Atarax) in infants and children?
- A. Reye's syndrome.
- B. cholinergic effects.
- C. paradoxical CNS stimulation.
- D. nausea and diarrhea.
Correct Answer: C
Rationale: The correct answer is paradoxical CNS stimulation. First-generation OTC antihistamines, such as diphenhydramine and hydroxyzine, can lead to paradoxical CNS stimulation in infants and children. This phenomenon is characterized by symptoms like excitement, euphoria, restlessness, and confusion, rather than the expected sedative effect. Due to this unexpected response, these antihistamines are used less frequently in pediatric populations. Reye's syndrome is a rare systemic response to a virus and is not a side effect of antihistamines. First-generation OTC antihistamines do not typically exhibit cholinergic effects. Nausea and diarrhea are uncommon side effects of these antihistamines and are less commonly observed than paradoxical CNS stimulation.
A client had a C5 spinal cord contusion that resulted in quadriplegia. Two days after the injury occurred, the nurse sees his mother crying in the waiting room. The mother asks the nurse whether her son will ever play football again. Which of the following is the best initial response?
- A. "Given time and motivation, your son may regain some function, but I will seek more information from the physician."?
- B. Maintain a calm demeanor and speech pattern while addressing the mother's concerns.
- C. "I'm not sure, but I'll call the physician to discuss this with you promptly."?
- D. "It's not beneficial for your son if you get upset."?
Correct Answer: C
Rationale: The best initial response in this situation is to acknowledge the mother's concern, express uncertainty, and offer to obtain more information from the physician. By saying, "I'm not sure, but I'll call the physician to discuss this with you promptly,"? the nurse demonstrates empathy, honesty, and a commitment to providing accurate information. Offering vague reassurance (Choice A) may raise false hopes as outcomes for spinal cord injuries are unpredictable. While maintaining a calm demeanor (Choice B) is important, it does not directly address the mother's immediate need for information. Discouraging the mother from feeling upset (Choice D) is dismissive of her emotions and does not address her question, which is seeking information about her son's prognosis.