The client is at highest risk for developing--------- eviden...

A nurse is caring for a client in an outpatient clinic.
Laboratory Results
First office visit:
Erythrocyte sedimentation rate (ESR) 21 mm/hr (up to 20 mm/hr)
Hct 36% (37 to 47%6)
Hgb 12 g/dL (12 to 16 g/dL)
WBC count 6000/mm³ (5,000 to 10,000/mm³)
Uric acid 6.1 mg/dL (2.7 to 7.3 mg/dL)
6-month follow-up:
Erythrocyte sedimentation rate (ESR) 22 mm/hr (up to 20 mm/hr)
Antinuclear antibodies (ANA) positive
Hct 35% (37 to 47%)
Hgb 11 g/dL (12 to 16 g/dL)
WBC 4000/mm³ (5,000 to 10,000/mm³)
Uric acid 6,3 mg/dL (2.7 to 7.3 mg/dL)

The client is at highest risk for developing--------- evidenced by the client's--------

A. Rheumatoid arthritis
B. decreased Hct and Hgb levels
C. ESR level
D. Systemic lupus erythematosus
E. Anemia evidenced by the client's
F. Gout evidenced
G. decreased WBC count

Correct Answer: D,G

Rationale: Decreased WBC count and elevated ESR suggest systemic lupus erythematosus.

A nurse is reviewing the medical records of four clients.

The nurse should identify that which of the following client findings requires follow-up care?

A. A client who received a Mantoux test 48hr ago and has an induration
B. A client who is schedule for a colonoscopy and is taking sodium phosphate
C. A client who is taking warfarin and has an INR of 1.8(low INR clotting)
D. A client who is takin bumetanide and has a potassium level of 3.6 mEq/L

Correct Answer: C

Rationale: The correct answer is C. A client taking warfarin with an INR of 1.8 requires follow-up care because it indicates insufficient anticoagulation, putting the client at risk for clot formation. An INR of 1.8 is below the therapeutic range (usually 2-3 for most indications) for warfarin therapy. This can lead to inadequate prevention of blood clots, increasing the risk of thromboembolic events. Follow-up care may involve adjusting the warfarin dosage to achieve the target INR range.

Choice A is incorrect because an induration after a Mantoux test is an expected finding and does not necessarily require follow-up care. Choice B is incorrect as taking sodium phosphate before a colonoscopy is a standard preparation and does not indicate a need for immediate follow-up care. Choice D is incorrect as a potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L

A home health nurse is planning care for a client who has Alzheimer's disease.

Which of the following actions should the nurse include in the plan of care?

A. Encourage physical activity prior to bedtime
B. Replace the carpet with hardwood floors
C. Wear clothing with zippers instead of buttons
D. Place locks at the top of exterior doors

Correct Answer: D

Rationale: The correct answer is D: Place locks at the top of exterior doors. This action is crucial in ensuring the safety and security of the individual, especially in cases where the person may be at risk of wandering or elopement. Placing locks at the top of exterior doors can prevent the individual from leaving the house unsupervised, which is essential for their safety. Encouraging physical activity prior to bedtime (A) may disrupt sleep patterns. Replacing carpet with hardwood floors (B) is not directly related to the safety of the individual. Wearing clothing with zippers instead of buttons (C) may be a personal preference but does not address safety concerns.

A nurse is planning care for a client who is scheduled to receive a transfusion of packed RBCs.

Which of the following actions should the nurse plan to take?

A. Use a solution of 0.9% sodium chloride to flush the transfusion tubing.
B. Prime the transfusion tubing with lactated Ringer's solution.
C. Administer the transfusion through a 24-gauge IV catheter.
D. Infuse the blood over a maximum of 6 hours.

Correct Answer: A

Rationale: The correct answer is A. Using a solution of 0.9% sodium chloride to flush the transfusion tubing is essential to ensure compatibility and prevent potential reactions between the blood product and other solutions. This is a standard practice to maintain the integrity of the blood product and prevent contamination. Flushing with lactated Ringer's solution (B) would introduce a different electrolyte composition that may affect the blood product. Administering the transfusion through a 24-gauge IV catheter (C) may not be appropriate for blood transfusions due to the risk of hemolysis or clotting. Infusing the blood over a maximum of 6 hours (D) is a general guideline for blood transfusions but is not the immediate action the nurse should plan to take.

A nurse in an antepartum unit is caring for a client.
Nurses' Notes
2000:
Client is 38-year-old, G4 P3 at 38 weeks of gestation. Presents for evaluation of labor and
spontaneous rupture of membranes (SROM). Client states, "My water broke a couple of hours
ago and is a greenish color." Client also reports contractions began about 4 hr ago and have
become consistently stronger and closer together.
Electronic fetal monitor applied. Small amount of thin green fluid noted on perineal pad.
Contraction palpated, lasted 40 seconds, moderate in intensity. Fetal heart rate (FHR) 165/min.
Vaginal examination performed: cervix 4 cm dilated, 70% effaced, 0 station, vertex presentation.
Client reports a history of chronic hypertension that has been well-controlled during this
pregnancy. Also, states were diagnosed with gestational diabetes at 28 weeks of gestation.
Vital Signs
2000:
Temperature 36.7° C (98.1° F)
Heart rate 98/min
Respiratory rate 20/min
Blood pressure 128/84 mm Hg
Oxygen saturation 98% on room air

Select the 2 findings that require immediate follow-up.

A. Blood pressure
B. Duration of contraction
C. Fetal heart rate
D. Fetal station
E. Characteristics of amniotic fluid

Correct Answer: C,E

Rationale: An elevated fetal heart rate and meconium-stained amniotic fluid indicate potential distress, necessitating urgent intervention.

A nurse is caring for a client who has placenta previa.

Which finding should the nurse expect?

A. Spotting
B. Painless, bright red vaginal bleeding
C. Soft, relaxed, and non-tender uterus
D. Fundal height greater than expected for gestational age
E. Fetal heart rate within normal limits unless significant blood loss occurs

Correct Answer: B

Rationale: The correct answer is B: Painless, bright red vaginal bleeding. This finding is indicative of placenta previa, a condition where the placenta partially or completely covers the cervix. The bright red color indicates fresh bleeding. Spotting (choice A) is more commonly associated with implantation bleeding in early pregnancy. A soft, relaxed, and non-tender uterus (choice C) is not specific to any particular condition. A fundal height greater than expected for gestational age (choice D) could indicate fetal macrosomia or polyhydramnios, but it is not related to the scenario described. While fetal heart rate within normal limits (choice E) is important, it is not the most relevant finding in this case.