Nokea
The nurse has just admitted a 35-year-old female client who has a serum vitamin B12 concentration of 800 pg/mL. Which of the following laboratory findings should cue the nurse to focus the client history assessment on specific drug or alcohol use?
- A. Total bilirubin, 0.3 mg/dL.
- B. Serum creatinine, 0.5 mg/dL.
- C. Hemoglobin, 16 g/dL.
- D. Folate, 1.5 ng/mL.
Correct Answer: D
Rationale: A serum vitamin B12 level of 800 pg/mL is within the normal range (200–900 pg/mL), but a folate level of 1.5 ng/mL is low (normal: 2.7–17 ng/mL). Low folate levels can be associated with chronic alcohol use, as alcohol impairs folate absorption and metabolism. The nurse should assess the client's history for alcohol use, as this may contribute to the folate deficiency. The other lab values (bilirubin, creatinine, hemoglobin) are normal and do not suggest drug or alcohol use.
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A client who has been diagnosed with peripheral vascular disease (PVD) is being discharged. The client needs further instruction if she says she will:
- A. Avoid heating pads
- B. Not cross her legs
- C. Wear leather shoes
- D. Use iodine on an injured site
Correct Answer: D
Rationale: Using iodine on an injured site is incorrect, as it can be cytotoxic and impair wound healing in PVD, where tissue perfusion is already compromised. Avoiding heating pads (risk of burns), not crossing legs (improves circulation), and wearing leather shoes (protects feet) are appropriate self-care measures.
A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea; the temperature is 100.6°F (38.1°C). Which of the following would be a priority outcome for this client?
- A. Prevention of urinary tract complications.
- B. Alleviation of nausea.
- C. Alleviation of pain.
- D. Maintenance of fluid and electrolyte balance.
Correct Answer: C
Rationale: Severe flank pain is the most urgent issue, making pain alleviation the priority outcome to ensure client comfort and stability.
The nurse is assessing a 42-year-old client with cancer. He has lost 1 lb in 4 weeks. He is taking ondansetron (Zofran) for nausea. He has a temperature of 101°F (38.3°C). The fever is indicative of:
- A. Inadequate nutrition.
- B. New resistance to current antiemetic therapy.
- C. Expected response to chemotherapy treatment.
- D. Infection.
Correct Answer: D
Rationale: A fever of 101°F in a cancer patient, especially during chemotherapy, is most likely indicative of infection, which requires prompt evaluation due to immunosuppression.
A client who has a history of mitral valve prolapse tells the nurse that she is scheduled to get her teeth cleaned. Which of the following replies by the nurse is most appropriate?
- A. The physician will need to reevaluate the status of your heart condition before your dental appointment.'
- B. The nurse to remind your dentist that you have a heart condition.'
- C. It is important for you to care for your teeth because your heart condition makes you more susceptible to developing oral infections.'
- D. We will prescribe a prophylactic antibiotic for you to take before getting your teeth cleaned.'
Correct Answer: D
Rationale: Clients with mitral valve prolapse may require prophylactic antibiotics before dental procedures to prevent infective endocarditis, depending on current guidelines. This is the most appropriate response as it directly addresses the need for preventive measures. The other options either lack specificity or do not address the immediate clinical concern.
When developing a discharge plan to manage the care of a client with chronic obstructive pulmonary disease (COPD), the nurse should advise the client to expect to:
- A. Develop respiratory infections easily.
- B. Maintain current status.
- C. Require less supplemental oxygen.
- D. Show permanent improvement.
Correct Answer: A
Rationale: COPD clients are prone to respiratory infections due to impaired lung defenses. Maintaining status is possible but not an expectation. Oxygen needs may increase, and COPD is progressive, not permanently improved.