Nokea
The nurse is caring for a client with a history of bipolar disorder who is receiving valproic acid (Depakote) 500 mg PO bid. Which of the following laboratory results should the nurse report immediately?
- A. Liver enzymes elevated to twice normal.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: Elevated liver enzymes suggest hepatotoxicity, a serious valproic acid side effect. Options B, C, and D are normal.
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A client comes to the clinic for treatment of recurrent pelvic inflammatory disease (PID). The nurse recognizes that this condition most frequently follows which type of infection?
- A. Trichomoniasis
- B. Chlamydia
- C. Staphylococcus
- D. Streptococcus
Correct Answer: B
Rationale: Chlamydia. Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.
The nurse is admitting a client to the unit from the postoperative recovery area after abdominal exploratory surgery.
After determining the client's vital signs, which of the following activities should the nurse perform next?
- A. Position the client on her left side, supported with pillows.
- B. Check the chart and determine the status of the fluid balance from surgery.
- C. Check the client's abdominal dressing for any evidence of bleeding.
- D. Monitor the incision and pulmonary status for the presence of infection.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) implementation, complete assessment first (2) assessment, determine what is happening to the patient now (3) correct-assessment, dressing should be checked on admission to the room and frequently for the next several hours (4) inappropriate assessment, it is too soon for infection to occur secondary to surgery
The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with a diagnosis of congestive heart disease. Which other finding is most likely to occur?
- A. Chest pain
- B. Peripheral edema
- C. Nail clubbing
- D. Lethargy
Correct Answer: B
Rationale: Peripheral edema. Bibasilar crackles and peripheral edema are common in congestive heart failure due to fluid overload.
A client is receiving heparin via continuous IV infusion for management of deep vein thrombosis (DVT). The partial thromboplastin time (PTT) is 1.5 times greater than normal.
Which of the following actions by the nurse is MOST appropriate?
- A. Discontinue the heparin infusion.
- B. Slow down the heparin infusion.
- C. Check the prothrombin time (PT) results.
- D. Continue to monitor the client.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each answer. (1) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range (2) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range (3) prothrombin time (PT) Test is useful for assessing warfarin (Coumadin) therapy (4) correct-expected result of heparin therapy is a prolonged PTT of 1.5 times the control, without signs of hemorrhage
An eight-year-old receiving chemotherapy for six months.
Which of the following responses by the nurse is BEST?
- A. Are you afraid of dying?'
- B. Why do you ask that question?'
- C. Only God knows that answer.'
- D. We won't leave you alone.'
Correct Answer: A
Rationale: Strategy: Remember therapeutic communication. (1) correct-encourages ventilation of thoughts and feelings regarding the concern (2) inappropriate (3) ignores the child's concern with dying (4) ignores the child's concern with dying