Nokea
Because a client is scheduled for a liver biopsy, the nurse should check to be sure that which laboratory test results have been received?
- A. Serum electrolytes
- B. Prothrombin time
- C. CBC with differential
- D. Serum creatinine
Correct Answer: B
Rationale: Liver biopsy carries a risk of bleeding due to the liver's vascular nature. Prothrombin time assesses clotting ability, critical to ensure the client can safely undergo the procedure without excessive bleeding risk. Electrolytes, CBC, and creatinine are less directly related to bleeding risk.
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The nurse is observing a nursing assistant providing care. Which action indicates that the nursing assistant understands universal precautions?
- A. The nursing assistant washes hands first thing in the morning before giving care to any client and again after all morning care is completed.
- B. The nursing assistant wears gloves during all client contact.
- C. The nursing assistant wears a gown when changing linen soiled with urine and feces.
- D. The nursing assistant changes gloves between clients but does not wash hands if gloves have been worn.
Correct Answer: C
Rationale: Wearing a gown for soiled linen contact adheres to universal precautions, preventing contamination. Limited hand washing, excessive gloves, or no hand washing post-gloves are incorrect.
Laboratory Results
Glucose - Fasting
70–110 mg/dL
(3.9–6.1 mmol/L) 650 mg/dL
(36.1 mmol/L)
A nurse is caring for 4 clients. Which prescription by the health care provider would the nurse question and seek further clarification before administering?
- A. 0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours
- B. IV bolus of 1000 mL 0.9% sodium chloride solution for a client in anaphylaxis due to a food allergy
- C. IV bolus of 1000 mL 0.9% sodium chloride solution for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dL (36.1 mmol/L)
- D. IV mannitol 25% solution for a client with a closed head injury who is exhibiting signs of increased intracranial pressure
Correct Answer: C
Rationale: 0.45% saline is appropriate for gastroenteritis to replace fluids. 0.9% saline bolus treats anaphylactic shock. Mannitol reduces intracranial pressure. A 1000 mL bolus for DKA is excessive; smaller boluses (e.g., 250-500 mL) are safer to avoid fluid overload.
The nurse is administering hygienic care to an elderly client in her home. What should the nurse wash first?
- A. Perineal area
- B. Face
- C. Upper torso
- D. Hands
Correct Answer: B
Rationale: Washing the face first during hygienic care respects client comfort and dignity, starting with a less invasive area. It also prevents cross-contamination from dirtier areas like the perineum.
A home health nurse is managing care for an adolescent client with cystic fibrosis. Which of the following potential complications should the nurse consider when developing a nursing care plan? Select all that apply.
- A. Chronic hypoxemia
- B. Diabetes insipidus
- C. Frequent respiratory infections
- D. Obesity
- E. Vitamin deficiencies
Correct Answer: A,C,E
Rationale: Cystic fibrosis causes chronic hypoxemia , frequent infections , and vitamin deficiencies due to malabsorption. Diabetes insipidus is unrelated, and obesity is unlikely due to high metabolic demand.
After the shift report in a labor and delivery unit which of these clients would the nurse check first?
- A. A middle aged woman with asthma and Type 1 diabetes mellitus has a BP of 150/94
- B. A middle aged woman with a history of two prior vaginal term births is 2 cm dilated
- C. A young woman who is a grand multipara has cervical dilation of 4 cm and is 50% effaced
- D. An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum
Correct Answer: D
Rationale: This client has an actual complication. The others present with findings of potential complications. The adolescent’s symptoms suggest a serious condition, possibly pulmonary edema or fetal demise, requiring immediate assessment.