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The nurse is caring for a client with a history of chronic kidney disease who is receiving epoetin alfa (Epogen). Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Hemoglobin 14 g/dL.
- B. Potassium 4.5 mEq/L.
- C. Creatinine 3.0 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: A hemoglobin of 14 g/dL is too high for epoetin alfa therapy, increasing the risk of hypertension and thrombosis, requiring dose adjustment. Options B, C, and D are expected: potassium 4.5 mEq/L and calcium 9.0 mg/dL are normal, and creatinine 3.0 mg/dL is consistent with chronic kidney disease.
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A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's constantly saying 'no' and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?
- A. Trust
- B. Initiative
- C. Independence
- D. Self-esteem
Correct Answer: C
Rationale: Independence. In Erikson's theory of development, toddlers struggle to assert independence, often using the word 'no' to establish autonomy.
A woman is in active labor with her first child when her membranes rupture. She voices a concern to the nurse that she is afraid of having a 'dry labor.' Which of the following responses by the nurse would be MOST appropriate?
- A. The amniotic fluid provides only minimal lubrication for the labor process.
- B. The amniotic sac may impede the progress of labor and is often ruptured artificially.
- C. Labor is only slightly more difficult with early rupture of the amniotic sac.
- D. Because there is limited amniotic fluid, additional fluids will be supplied.
Correct Answer: B
Rationale: Rupture of membranes can facilitate labor by removing the sac, which may impede progress, addressing the client’s 'dry labor' concern. Options A, C, and D are incorrect: amniotic fluid has multiple roles, labor difficulty is not significantly increased, and no fluids are added.
Because a client has Guillain-Barré syndrome, the nurse would expect which of the following in the client's history?
- A. Recent upper respiratory infection
- B. A tick bite a few days ago
- C. A mosquito bite a week ago
- D. A strep throat infection two weeks ago
Correct Answer: A
Rationale: Guillain-Barré syndrome is often preceded by a viral upper respiratory infection, triggering an autoimmune response, unlike tick bites, mosquito bites, or strep throat.
A nurse was sued for malpractice but is proved innocent.
Which fact from the case was decisive in determining the outcome?
- A. Negligence was implied.
- B. The suit was filed under the law of negligent tort.
- C. No harm was actually suffered by the patient.
- D. The nurse failed to give competent care.
Correct Answer: C
Rationale: Strategy: Think about each answer. (1) negligence is the unintentional failure of an individual to perform an act that a reasonable person would or not would perform in similar circumstances; can be an act of omission or commission (2) tort is a legal term that means a wrongful act that results in injury, loss, or damage (3) correct-required elements of malpractice are duty, breach of duty, causation, and injury (4) would be considered negligence
An adult is taking digoxin and furosemide. Which laboratory value is of greatest concern to the nurse?
- A. Serum digoxin of 1.2 ng/mL
- B. Serum K+ of 3.0 mEq/L
- C. BUN of 12 mg/dL
- D. Serum Mg of 1.6 mEq/L
Correct Answer: B
Rationale: Furosemide, a diuretic, can cause hypokalemia (low potassium), increasing the risk of digoxin toxicity. A serum K+ of 3.0 mEq/L is below normal (3.5-5.0 mEq/L), posing a significant risk. The digoxin level is therapeutic (0.5-2.0 ng/mL), and BUN and Mg are within normal ranges.