The nurse is caring for a client with a history of ulcerative colitis.
- A. Which laboratory finding is most concerning for a client with ulcerative colitis?
- B. Hemoglobin of 10.5 g/dL.
- C. White blood cell count of 15,000/mm³.
- D. Serum potassium of 3.8 mEq/L.
- E. Albumin of 3.0 g/dL.
Correct Answer: B
Rationale: A white blood cell count of 15,000/mm³ suggests infection or severe inflammation in ulcerative colitis, requiring immediate attention. Low hemoglobin and albumin are common, and normal potassium is unremarkable.
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A 13 year old girl is admitted to the ER with lower right abdominal discomfort. The admitting nursing should take which the following measures first?
- A. Administer Loritab to the patient for pain relief.
- B. Place the patient in right sidelying position for pressure relief.
- C. Start a Central Line.
- D. Provide pain reduction techniques without administering medication.
Correct Answer: D
Rationale: Do not administer pain medication or start a central line without MD orders.
A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to
- A. Administer pain medication
- B. Suction excessive tracheobronchial secretions
- C. Assist client to turn, deep breathe and cough
- D. Monitor oxygen saturation
Correct Answer: B
Rationale: Suction excessive tracheobronchial secretions. Suctioning the copious tracheobronchial secretions present in post-thoracic surgery clients maintains an open airway, which is always the priority nursing intervention.
The nurse is caring for a homebound client with a urinary catheter. The client's husband states that he thinks the catheter is obstructed. Which of the following observations would confirm this suspicion?
- A. The nurse notes that the bladder is distended.
- B. The client complains of a constant urge to void.
- C. The nurse notes that the urine is concentrated.
- D. The client complains of a burning sensation.
Correct Answer: A
Rationale: bladder distention is one of the earliest signs of obstructed drainage tubing
The nurse is caring for a client who is receiving IV gentamicin for a gram-negative infection. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Creatinine 2.5 mg/dL.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: A creatinine of 2.5 mg/dL indicates renal impairment, a serious complication of gentamicin due to nephrotoxicity, requiring immediate evaluation. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and hemoglobin 13 g/dL do not indicate complications.
Which contraindication should the nurse assess for prior to giving a child immunizations?
- A. Mild cold symptoms
- B. Chronic asthma
- C. Depressed immune system
- D. Allergy to eggs
Correct Answer: C
Rationale: Depressed immune system. Children who have a depressed immune system related to HIV or chemotherapy should not be given routine immunizations.
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