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An older client with diabetes is admitted with a heavily draining leg wound. The client's white blood cell count is 38,000/mm³ but the client is afebrile. What action does the nurse take first?
- A. Administer acetaminophen (Tylenol)
- B. Place the client on contact isolation
- C. Refer the client to the wound care nurse
- D. Obtain wound cultures
Correct Answer: C
Rationale: A heavily draining wound suggests potential infection, and the elevated white blood cell count supports this. Placing the client on contact isolation is the priority to prevent the spread of infection. Acetaminophen is unnecessary without fever, wound cultures follow isolation, and referral to a wound care nurse is secondary.
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A nurse sees clients in an osteoporosis clinic. Which client should the nurse see first?
- A. Client taking calcium with vitamin D (Os-Cal) who reports flank pain 6 weeks ago
- B. Client taking ibandronate (Boniva) who cannot remember when the last dose was
- C. Client taking raloxifene who reports leg swelling 6 weeks ago
- D. Client taking risedronate (Actonel) who reports occasional dyspepsia
Correct Answer: C
Rationale: Leg swelling in a client taking raloxifene suggests possible deep vein thrombosis, a serious adverse effect requiring immediate attention. Flank pain from 6 weeks ago is less urgent, forgetting a dose of ibandronate is not immediately critical, and dyspepsia with risedronate is a common side effect that can be managed later.
A client is admitted with a bone tumor. The nurse finds the client weak and lethargic with decreased deep tendon reflexes. What actions by the nurse are best? (Select all that apply.)
- A. Assess the daily serum calcium level
- B. Consult the provider about a loop diuretic
- C. Institute seizure precautions for the client
- D. Raise the head of the bed
- E. Place the client on a 1500 mL fluid restriction
Correct Answer: A,B,D
Rationale: Weakness, lethargy, and decreased reflexes suggest hypercalcemia, common in bone tumors. Assessing serum calcium, consulting for loop diuretics, and raising the head of the bed to promote safety are appropriate. Seizure precautions and fluid restrictions are not indicated.
A client is scheduled for a bone biopsy. What action by the nurse takes priority?
- A. Administering the prescribed oral medication
- B. Answering any questions about the procedure
- C. Ensuring that informed consent is on the chart
- D. Showing the client's family where to wait
Correct Answer: C
Rationale: Ensuring informed consent is on the chart is the priority before a bone biopsy to confirm the client's understanding and agreement to the procedure. Medications, answering questions, and guiding the family are important but secondary.
A client has a bone density score of 2.8. What action by the nurse is best?
- A. Asking the client to keep a food diary
- B. Planning to teach about bisphosphonates
- C. Scheduling another scan in 2 years
- D. Scheduling another scan in 2 months
Correct Answer: B
Rationale: A T-score of 2.5 or lower indicates osteoporosis. The nurse should plan to teach about medications used to treat this disease, such as bisphosphonates. A food diary may help assess calcium and vitamin D intake, but dietary changes alone are insufficient at this stage. Scheduling another scan does not address immediate treatment needs.
The nurse sees several clients with osteoporosis. For which client would bisphosphonates not be a good option?
- A. Client with diabetes who has a serum creatinine of 0.8 mg/dL
- B. Client who recently fell and has vertebral compression fractures
- C. Hypertensive client who takes calcium channel blockers
- D. Client with a spinal cord injury who cannot tolerate sitting up
Correct Answer: D
Rationale: Bisphosphonates require the client to sit upright for 30"?60 minutes after administration to prevent esophageal irritation. A client with a spinal cord injury who cannot tolerate sitting up is not a good candidate. A serum creatinine of 0.8 mg/dL is normal, and neither vertebral fractures nor calcium channel blockers contraindicate bisphosphonates.