Nokea
The nurse is caring for a client with acute pancreatitis. While obtaining the client's blood pressure, the nurse notes a carpal spasm. The nurse should obtain a blood specimen to check the client's serum
- A. calcium level
- B. albumin level
- C. troponin T level
- D. potassium level
Correct Answer: A
Rationale: Carpal spasm (Trousseau's sign) suggests hypocalcemia (A), common in pancreatitis. Albumin (B), troponin (C), and potassium (D) are unrelated to this finding.
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The nurse is caring for a client receiving treatment for benign prostatic hyperplasia. Which client statement requires further investigation?
- A. I have a burning sensation when I urinate.
- B. I have been having some dribbling after I finish urinating.
- C. I missed 3 days of finasteride while on a trip last week.
- D. I was awakened 3 times last night by the need to urinate.
Correct Answer: A
Rationale: Burning on urination (A) suggests a urinary tract infection, requiring investigation. Dribbling (B), nocturia (D), and missing doses (C) are common with BPH or medication non-adherence but less urgent.
A new mother asks the nurse when the baby's umbilical cord will fall off. The nurse replies that it usually takes how many days to detach?
- A. 1-2 days
- B. 3-5 days
- C. 7-10 days
- D. 15-20 days
Correct Answer: C
Rationale: The umbilical cord typically detaches within 7-10 days as it dries and separates naturally, a standard newborn care fact.
The nurse is caring for a client with benign prostatic hypertrophy (BPH). Which of the following assessments would the nurse anticipate finding?
- A. Large volume of urinary output with each voiding
- B. Involuntary voiding with coughing and sneezing
- C. Frequent urination
- D. Urine is dark and concentrated
Correct Answer: C
Rationale: Frequent urination. BPH causes overflow incontinence with frequent urination in small amounts due to bladder obstruction.
There has been a large-scale community disaster and clients must be roomed together at the hospital. Who are appropriate roommates in light of infection risk principles?
- A. A client diagnosed with varicella and a client with pertussis
- B. A client placed in an airborne infection isolation room (AIIR) and a client with heart failure
- C. A client receiving chemotherapy and a client with chronic obstructive pulmonary disease (COPD) coughing yellow sputum
- D. A client with pelvic inflammatory disease (PID) and a client with coffee ground emesis
- E. Two clients diagnosed with tuberculosis
Correct Answer: D
Rationale: PID and coffee ground emesis (D) are non-infectious, making them suitable roommates. Varicella, pertussis, TB (A, E), and COPD with sputum (C) pose infection risks. AIIR (B) is for airborne infections, incompatible with heart failure.
The nurse preceptor observes a graduate practical nurse collecting a urine sample for urinalysis and culture as pictured in the exhibit. What is the preceptor's best action?
- A. Advise the graduate nurse to discard the collected urine specimen and record the output
- B. Advise the graduate nurse to use a sterile specimen cup rather than a graduated container for collection
- C. Explain to the graduate nurse that midstream clean catch or straight catheterization is required
- D. Remind the graduate nurse that the specimen should be kept cool until it is sent to the laboratory
Correct Answer: C
Rationale: Urine for culture requires a midstream clean catch or catheterization (C) to avoid contamination. A graduated container (B) is acceptable if sterile. Discarding (A) is unnecessary, and cooling (D) is secondary.