Nokea
An African-American client is admitted with full thickness burns over 40% of his body. In addition to the CBC and complete metabolic panel, the physician is likely to request which additional lab work?
- A. Erythrocyte sedimentation rate
- B. Indirect Coombs
- C. C reactive protein
- D. Sickledex
Correct Answer: D
Rationale: Sickle cell anemia and sickle cell trait are more prevalent in African American clients. The Sickledex test detects the presence of sickle cell anemia and sickle cell trait. Trauma can trigger a sickle cell crisis, which would complicate the treatment of the client. Answers A and C indicate inflammation, so they are incorrect. Answer B is incorrect because it detects circulating antibodies against RBCs.
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The LPN/LVN is to perform a sterile procedure. Which action will maintain a sterile field?
- A. Keeping the sterile field within the line of vision
- B. Opening sterile packages with sterile gloves
- C. Talking to others over the sterile field
- D. Handing the physician medicine over the sterile field
Correct Answer: A
Rationale: Keeping the sterile field in view ensures no contamination occurs, maintaining sterility during the procedure.
The nurse is caring for a client who is 4 days post-op for a transverse colostomy. The client is ready for discharge and asks the nurse to empty his colostomy pouch. What is the best response by the nurse?
- A. You should be emptying the pouch yourself.'
- B. Let me demonstrate to you how to empty the pouch.'
- C. What have you learned about emptying your pouch?'
- D. Show me what you have learned about emptying your pouch.'
Correct Answer: D
Rationale: Most adult learners obtain skills by participating in the activities. Anxiety about discharge can be causing the client to forget that they have mastered the skill of emptying the pouch. The client should show the nurse how the pouch is emptied.
An 11-year-old boy with a minor head injury treated at the outpatient clinic.
The nurse determines that further teaching is necessary if the mother makes which of the following statements? dimensional visualization of the vertebral canal.'
- A. My son may have dizziness for 24 hours.'
- B. My son can drink carbonated beverages if he vomits.'
- C. My son may complain of nausea.'
- D. My son will probably have a headache.'
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to a minor head injury. (1) expected for at least 24 hours (2) correct-unexpected, should be reported to physician immediately, also unexpected is blurred vision, drainage from ear or nose, weakness, slurred speech, worsening headache (3) expected for at least 24 hours (4) expected for at least 24 hours, should not get more intense
The client with cancer of the larynx is admitted to the unit with Acute Respiratory Distress Syndrome. Which nursing diagnosis should receive priority?
- A. Alteration in oxygen perfusion
- B. Alteration in comfort/pain
- C. Alteration in mobility
- D. Alteration in sensory perception
Correct Answer: A
Rationale: Acute Respiratory Distress Syndrome causes severe hypoxemia, making alteration in oxygen perfusion the priority nursing diagnosis to ensure adequate oxygenation. Pain , mobility , and sensory perception are secondary in this life-threatening condition.
In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust?
- A. Food
- B. Warmth
- C. Security
- D. Comfort
Correct Answer: C
Rationale: Security. Providing consistent, loving care fosters trust, a key developmental need for infants per Erikson's theory.