Nokea
The healthcare provider is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition?
- A. Low serum albumin level
- B. Low serum transferrin level
- C. High hemoglobin level
- D. High cholesterol level
Correct Answer: A
Rationale: A low serum albumin level is the most reliable indicator of chronic protein malnutrition. Serum albumin levels reflect long-term protein status, and a significantly lowered level usually indicates ongoing protein deficiency. Other laboratory values, such as serum transferrin, hemoglobin, or cholesterol levels, may be affected by various factors and conditions, but serum albumin is a more specific marker for chronic protein malnutrition.
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While the nurse is discharging an adult woman who was hospitalized for 6 days for treatment of pneumonia and reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement?
- A. Instruct the client to repeat the medication plan
- B. Encourage the client to take a PRN antianxiety drug
- C. Provide written instructions that are easy to follow
- D. Include a family member in the teaching session
Correct Answer: A
Rationale: In this situation, the most important action for the nurse to implement is to instruct the client to repeat the medication plan. By using the teach-back method, the nurse can ensure the client's understanding of the prescribed medications and address any concerns or anxieties the client may have. This approach promotes patient engagement, active participation, and retention of important information, ultimately enhancing medication adherence and safety.
An elderly patient has been living in a nursing home for several years. The nursing staff has begun to notice a change in her behavior. All of the following are symptoms of depression except:
- A. Changes in sleep patterns
- B. Changes in eating patterns with weight loss
- C. Excessive fatigue and increased concern with bodily functions
- D. Hyperorality
Correct Answer: D
Rationale: Hyperorality is not typically a symptom of depression. Symptoms of depression often include changes in sleep patterns, eating patterns with weight loss, and excessive fatigue. Hyperorality, which refers to the tendency to examine, chew, or ingest non-nutritive substances, is not a common symptom associated with depression.
A client with stage 4 lung cancer receiving in-home hospice care expresses concerns about pain while the nurse is arranging for discharge. What action should the nurse take?
- A. Explain the potential respiratory issues associated with morphine use.
- B. Educate the family on assessing the effectiveness of analgesics.
- C. Suggest requesting a patient-controlled analgesic (PCA) pump from the healthcare provider.
- D. Provide the client with a schedule for around-the-clock prescribed analgesic use.
Correct Answer: D
Rationale: In managing pain for a client with stage 4 lung cancer in hospice care, providing a schedule for around-the-clock prescribed analgesic use is essential. This approach ensures continuous pain control and helps prevent breakthrough pain. By having a consistent dosing schedule, the client can maintain a more stable level of pain relief, enhancing their comfort and quality of life during this critical time.
The healthcare provider is providing wound care to a client with a stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states 'clean the wound and then apply collagenase.' Collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the healthcare provider use to cleanse the pressure ulcer?
- A. Lightly coat the wound with povidone-iodine solution
- B. Irrigate the wound with sterile normal saline
- C. Flush the wound with sterile hydrogen peroxide
- D. Remove the eschar with a wet-to-dry dressing
Correct Answer: B
Rationale: The correct technique to cleanse a wound when the prescription does not specify a cleaning method is to irrigate the wound with sterile normal saline. Sterile normal saline is the preferred solution for wound cleaning as it is gentle and does not damage healthy tissues. It helps in removing debris and maintaining a moist environment conducive to healing. Povidone-iodine solution and hydrogen peroxide can be harsh on tissues and delay wound healing. Removing eschar with a wet-to-dry dressing is a mechanical debridement method and should not be done without proper assessment and healthcare provider's order.
A client with a history of diabetes mellitus is admitted with a blood glucose level of 600 mg/dL. What type of insulin should the nurse prepare to administer to this client?
- A. Regular insulin
- B. NPH insulin
- C. Lispro insulin
- D. Glargine insulin
Correct Answer: A
Rationale: In a client with a blood glucose level of 600 mg/dL, which indicates severe hyperglycemia or diabetic ketoacidosis, the nurse should prepare to administer regular insulin (A). Regular insulin has a rapid onset of action and is the preferred choice for immediate correction of high blood glucose levels. NPH insulin (B), lispro insulin (C), and glargine insulin (D) are not suitable for the rapid correction of severe hyperglycemia.