Nokea
The client is admitted to the unit with the following lab values. Which of the following lab values should be reported immediately?
- A. BUN $18 \mathrm{mg} / \mathrm{dL}$
- B. $\mathrm{PO}_2 72 \%$
- C. Hemoglobin $10 \mathrm{mg} / \mathrm{dL}$
- D. White blood cell count of 5,500
Correct Answer: B
Rationale: A $\mathrm{PO}_2$ of 72% indicates severe hypoxemia, requiring immediate intervention. BUN, hemoglobin, and WBC values are less urgent.
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A 26-year-old woman has missed her menstrual period. The client's last menstrual period began May 8 and ended May 12.
The nurse determines that her EDC (estimated date of confinement) is
- A. February 1.
- B. February 15.
- C. February 19.
- D. March 14.
Correct Answer: B
Rationale: Strategy: Remember Naegele's rule. (1) should add seven days (2) correct-when using the Naegele rule, add seven days to first day of last menstrual period and subtract three months (3) incorrectly started with the last day of the menstrual cycle (4) incorrect
The nurse is caring for a client with a history of rheumatoid arthritis who is receiving prednisone 10 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a headache sometimes.
- B. I feel tired in the afternoon.
- C. I have gained 5 pounds this month.
- D. I take my medication with food.
Correct Answer: C
Rationale: Weight gain of 5 pounds in a month suggests a side effect of prednisone, such as fluid retention or increased appetite, requiring evaluation to prevent complications like hypertension. Options A, B, and D are less concerning: headaches and fatigue are nonspecific, and taking with food is appropriate.
The mother of a 10-year-old boy with IDDM (insulin-dependent diabetes mellitus) calls to discuss the child’s self-monitoring blood glucose (SMBG) home readings. He is being tightly regulated with a combination of NPH and regular insulin before breakfast and supper. The past two mornings his blood sugar readings were 220 mg/dL and 210 mg/dL. The nurse should advise the mother to
- A. continue with his medication regime.
- B. check his blood sugar during the night.
- C. give his NPH insulin later in the evening.
- D. serve his bedtime snack earlier in the evening.
Correct Answer: B
Rationale: High morning blood sugars suggest rebound hyperglycemia (Somogyi effect) from nocturnal hypoglycemia, requiring nighttime glucose checks. Options A, C, and D are premature: continuing the regimen ignores the issue, and adjusting insulin or snack timing requires confirmation.
A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?
- A. Converse with the client to determine if the mucous membranes are impaired
- B. Report output of less than 30 ml/hr
- C. Provide oral fluids every hour
- D. Check skin turgor every 4 hours
Correct Answer: C
Rationale: Providing oral fluids is a routine task with predictable outcomes, suitable for a UAP, while the other tasks require clinical judgment or assessment skills.
The nurse is caring for a child with cystic fibrosis. The nurse would anticipate that the child would be deficient in which vitamins?
- A. B, D, and K
- B. A, D, and K
- C. A, C, and D
- D. A, B, and C
Correct Answer: B
Rationale: A, D, and K. The uptake of fat soluble vitamins is decreased in children with Cystic Fibrosis. Vitamins A, D, and K are fat soluble and are likely to be deficient in clients with Cystic Fibrosis.