Nokea
The nurse is caring for a client with a history of renal failure.
- A. Which laboratory finding is most concerning for a client with chronic renal failure?
- B. Serum creatinine of 2.5 mg/dL.
- C. Serum potassium of 6.2 mEq/L.
- D. Blood urea nitrogen of 30 mg/dL.
- E. Hemoglobin of 10.5 g/dL.
Correct Answer: B
Rationale: A serum potassium of 6.2 mEq/L indicates hyperkalemia, a life-threatening condition in renal failure due to impaired excretion, risking cardiac arrhythmias. Elevated creatinine, BUN, and low hemoglobin are expected but less urgent.
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The nurse is teaching a client with a new diagnosis of rheumatoid arthritis about methotrexate (Rheumatrex). Which of the following statements by the client indicates a need for further teaching?
- A. I should avoid drinking alcohol while taking this medication.
- B. I should take this medication with food.
- C. I should report any bruising to my doctor.
- D. I should stop this medication if my joints feel better.
Correct Answer: D
Rationale: Stopping methotrexate when joints feel better is incorrect, as rheumatoid arthritis requires ongoing treatment to prevent flares. Options A, B, and C are correct: alcohol increases hepatotoxicity, food reduces GI upset, and bruising may indicate thrombocytopenia.
When obtaining a specimen from a client for sputum culture and sensitivity (C and S), the nurse knows that which of the following instructions is BEST?
- A. After pursed-lip breathing, cough into a container.
- B. Upon awakening, cough deeply and expectorate into a container.
- C. Save all sputum for three days in a covered container.
- D. After respiratory treatment, expectorate into a container.
Correct Answer: B
Rationale: specimens should be obtained in the early morning because secretions develop during the night
The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?
- A. Irritability
- B. Slight edema at site
- C. Local tenderness
- D. Seizure activity
Correct Answer: D
Rationale: Seizure activity. Other reactions that should be reported include crying for >3 hours, temperature over 104.8 degrees Fahrenheit following DPT immunization, and tender, swollen, reddened areas.
Antibiotics are ordered for an adult who has a peptic ulcer. The client asks why antibiotics are prescribed. What should the nurse include when responding?
- A. Antibiotics are given to prevent secondary infections.
- B. Peptic ulcers are usually caused by bacteria.
- C. Antibiotics will create the environment necessary for the ulcers to heal.
- D. Antibiotics are given to prevent the infection from spreading to the bowel.
Correct Answer: B
Rationale: Peptic ulcers are often caused by Helicobacter pylori bacteria, and antibiotics eradicate the infection, promoting healing. They do not primarily prevent secondary infections, create healing environments, or stop bowel spread.
A Jewish client requires grafting to promote burn healing. Which graft is most likely to be unacceptable to the client?
- A. Isograft
- B. Autograft
- C. Homograft
- D. Xenograft
Correct Answer: D
Rationale: A Jewish client may find a xenograft unacceptable due to religious dietary laws that prohibit the use of certain animal products, such as porcine grafts. An isograft (from an identical twin), autograft (from the client's own body), and homograft (from a human donor) are generally more acceptable. Answers A, B, and C are incorrect because they do not typically conflict with Jewish religious beliefs.