Nokea
The client with liver cirrhosis needs immediate intervention for which abnormal laboratory result?
- A. Prothrombin time (PT) of 14 seconds.
- B. Bilirubin of 1.2 mg/dL.
- C. Albumin of 4 g/dL.
- D. Ammonia level of 80 mcg/dL.
Correct Answer: D
Rationale: An elevated ammonia level of 80 mcg/dL indicates hepatic encephalopathy, a serious complication of liver cirrhosis that requires immediate intervention. Ammonia is a neurotoxin that accumulates in the blood due to impaired liver function, leading to cognitive impairment and altered mental status. Monitoring and lowering ammonia levels are crucial in managing hepatic encephalopathy to prevent further neurological deterioration. Prothrombin time, bilirubin, and albumin levels are important parameters in assessing liver function and overall health status in clients with liver cirrhosis, but an elevated ammonia level poses an immediate threat to neurological function and warrants prompt attention.
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The healthcare provider is preparing to administer an intravenous (IV) medication to a client. Which action should the healthcare provider take first?
- A. Verify the client's identity using two identifiers.
- B. Check the client's allergy status.
- C. Prepare the medication for administration.
- D. Administer the medication at the prescribed rate.
Correct Answer: B
Rationale: Checking the client's allergy status is the priority before administering any medication, especially intravenously. This step helps identify any potential allergic reactions and prevents harm to the client. Verifying the client's identity using two identifiers is important but not the first step in medication administration. Preparing the medication for administration and administering the medication at the prescribed rate come after ensuring the client's safety by checking for allergies.
During a home visit, the nurse observes that a client with limited mobility has difficulty preparing meals. What should the nurse do first?
- A. suggest that the client use a meal delivery service
- B. assist the client in meal planning
- C. refer the client to a dietitian
- D. educate the client on easy-to-prepare healthy meals
Correct Answer: B
Rationale: Assisting the client in meal planning is the most appropriate initial action as it addresses the immediate issue of meal preparation. By helping the client plan meals according to their dietary needs and limitations, the nurse can support the client in maintaining a healthy diet despite limited mobility. While suggesting a meal delivery service (Choice A) may be a viable option, assisting in meal planning allows for more personalized and sustainable solutions. Referring the client to a dietitian (Choice C) may be necessary for specialized nutritional advice but is not the first step in addressing the immediate concern. Educating the client on easy-to-prepare healthy meals (Choice D) could be beneficial, but meal planning is a more comprehensive approach to ensure the client's dietary needs are met consistently.
A community health nurse is addressing the issue of domestic violence in the community. Which intervention should be prioritized?
- A. Providing education on the signs of domestic violence
- B. Setting up a support group for survivors
- C. Partnering with local law enforcement to increase patrols
- D. Creating a confidential hotline for reporting abuse
Correct Answer: D
Rationale: Creating a confidential hotline for reporting abuse is the most critical intervention when addressing domestic violence. A hotline offers a safe and confidential way for individuals experiencing abuse to report incidents, seek help, and access support services. This intervention prioritizes immediate safety and support for victims. Providing education on the signs of domestic violence (Choice A) is important for prevention but may not address the urgent needs of individuals currently experiencing abuse. Setting up a support group for survivors (Choice B) is valuable for emotional support but may not reach those who are not yet identified as survivors. Partnering with local law enforcement to increase patrols (Choice C) focuses more on the law enforcement response rather than providing a direct avenue for victims to seek help and support.
An 80-year-old client is given morphine sulfate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urinary retention in this geriatric client?
- A. Nonsteroidal anti-inflammatory agents.
- B. Antihistamines.
- C. Tricyclic antidepressants.
- D. Antibiotics.
Correct Answer: C
Rationale: The correct answer is C: Tricyclic antidepressants. Drugs with anticholinergic properties, such as tricyclic antidepressants, can exacerbate urinary retention associated with opioids in older clients. Nonsteroidal anti-inflammatory agents (Choice A) do not typically cause urinary retention. Antihistamines (Choice B) may cause urinary retention but are not the primary concern in this scenario. Antibiotics (Choice D) are not associated with an increased risk of urinary retention compared to tricyclic antidepressants.
The nurse is preparing an orientation class for new employees at an inner-city clinic that serves a low-income population. Which information should the nurse include in the presentation to these new employees?
- A. A lack of transportation is the major impediment for the clinic's clients.
- B. Basic physiological needs are likely to be unmet in this clinic's client population.
- C. Printed material is less effective for this population that has limited reading skills.
- D. A group education class is often poorly attended by non-compliant clients.
Correct Answer: A
Rationale: The correct answer is A. Addressing transportation issues is crucial when working with low-income populations as lack of transportation can be a significant barrier to accessing healthcare services. This information is important for new employees to understand the challenges faced by the clinic's clients and to strategize ways to overcome this barrier. Choices B, C, and D are incorrect because while they may be relevant considerations, addressing transportation barriers should be a priority given its impact on accessing care for this specific population.