Nokea
The client's total WBC count is 20,000/mm3 two days after surgery. Which assessment finding should the nurse most associate with this laboratory result?
- A. Respiratory rate slow and shallow
- B. Skin incision pink, crusty, and intact
- C. Dark amber urine per urinary catheter
- D. Diminished lung sounds with crackles
Correct Answer: D
Rationale: D: Elevated WBC and crackles suggest a respiratory infection. A: Slow respiration is unrelated. B: Normal incision appearance doesn't correlate. C: Amber urine indicates dehydration, not infection.
You may also like to solve these questions
A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse?
- A. Cut the child's hair short to remove the nits
- B. Apply warm soaks to the head twice daily
- C. Wash the child's linen and bedding in hot water
- D. Application of pediculicides
Correct Answer: D
Rationale: Application of pediculicides. Treatment of head lice consists of application of pediculicides. Pediculicides vary, and the directions must be followed carefully.
A client is being maintained on heparin therapy for deep vein thrombosis (DVT). The nurse must closely monitor which of the following laboratory values?
- A. bleeding time
- B. platelet count
- C. activated PTT
- D. clotting time
Correct Answer: C
Rationale: activated PTT. Heparin is used to prevent further clots from being formed and to prevent the present clot from enlarging. The Activated Prothromboplastin Time (APTT) test is a highly sensitive test to monitor the client on heparin.
The new nurse is caring for the client with a VRE infection. Which statement to the client indicates the new nurse needs additional orientation when caring for clients with a VRE infection?
- A. "All hospital staff should be wearing gown and gloves when they enter your room."
- B. "Visitors should use soap and water for hand washing when entering and leaving your room."
- C. "You are in a private room because VRE is transmitted by direct and indirect contact."
- D. "VRE is a new strain of enterococci bacteria normally found in a person's GI tract."
Correct Answer: A
Rationale: A: Gowns are only needed if clothing contamination is likely, indicating a need for further training. B, C, D: These statements are correct.
The nurse is using contact precautions for the client with Clostridium difficile. While the nurse transfers the client from the bed to the commode, the client has loose stool that falls on the floor. After positioning the client on the commode, how should the nurse proceed to cleanse the floor?
- A. Wipe up the stool with toilet paper and then clean the area with soap and water
- B. Wipe up the stool with toilet paper and then clean the area with a 1:10 bleach-water solution
- C. Call housekeeping personnel to come clean the floor now with the unit's mop and bucket
- D. Wipe up the stool and apply the alcohol-based hand wash to cleanse the area of stool
Correct Answer: B
Rationale: B: Bleach solution effectively kills C. difficile spores. A: Soap and water are insufficient. C: Housekeeping delays action and risks spread. D: Alcohol is ineffective against C. difficile.
While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response?
- A. As you urinate more, you will need less medication to control fluid.'
- B. You will have to take this medication for about a year.'
- C. The medication must be continued so the fluid problem is controlled.'
- D. Please talk to your health care provider about medications and treatments.'
Correct Answer: C
Rationale: The medication must be continued so the fluid problem is controlled.' This is the most therapeutic response and gives the client accurate information.