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The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should the nurse monitor closely?
- A. Serum potassium level
- B. Hemoglobin level
- C. White blood cell count
- D. Serum calcium level
Correct Answer: A
Rationale: The correct answer is A: Serum potassium level. When a client with chronic kidney disease (CKD) is receiving erythropoietin therapy, the nurse should closely monitor the serum potassium level. Erythropoietin therapy can stimulate red blood cell production, leading to an increased demand for potassium. This increases the risk of hyperkalemia, making it crucial to monitor potassium levels closely. Choices B, C, and D are incorrect because erythropoietin therapy primarily affects red blood cell production, not hemoglobin, white blood cell count, or serum calcium levels.
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A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention should the nurse implement first?
- A. Administer intravenous insulin as prescribed.
- B. Monitor the client's urine output.
- C. Administer intravenous fluids.
- D. Administer 50% dextrose IV push.
Correct Answer: A
Rationale: Administering intravenous insulin is the initial priority in managing diabetic ketoacidosis (DKA). Insulin helps to reduce blood glucose levels and correct metabolic acidosis, addressing the underlying cause of DKA. Monitoring urine output (choice B) is important but is not the first intervention needed. Administering intravenous fluids (choice C) is essential to correct dehydration in DKA, but insulin therapy takes precedence. Administering 50% dextrose IV push (choice D) is contraindicated in DKA as it can exacerbate hyperglycemia.
A client with a history of rheumatoid arthritis is prescribed prednisone. Which assessment finding requires immediate intervention?
- A. Increased joint pain
- B. Weight gain of 2 pounds in 24 hours
- C. Blood glucose level of 150 mg/dl
- D. Fever of 100.4°F
Correct Answer: B
Rationale: The correct answer is B. Weight gain of 2 pounds in 24 hours is concerning in a client with rheumatoid arthritis on prednisone as it may indicate fluid retention or worsening heart failure. Increased joint pain, blood glucose level of 150 mg/dl, and fever of 100.4°F are important assessments but do not require immediate intervention compared to the potential severity of rapid weight gain.
The nurse reviews the laboratory findings of a client with an open fracture of the tibia. The white blood cell (WBC) count and erythrocyte sedimentation rate (ESR) are elevated. Before reporting this information to the healthcare provider, what assessment should the nurse obtain?
- A. Appearance of wound
- B. Pain level
- C. Presence of fever
- D. Mobility status
Correct Answer: A
Rationale: The correct answer is A: Appearance of wound. Elevated WBC and ESR levels suggest a possible infection in the client with an open fracture. Assessing the wound's appearance is crucial to evaluate for signs of infection, such as redness, warmth, swelling, or drainage. By assessing the wound first, the nurse can provide important information to the healthcare provider regarding the potential infection, which may require immediate intervention. Choices B, C, and D are important assessments in caring for a client with an open fracture; however, in this scenario, the priority is to assess the wound for signs of infection due to the elevated WBC and ESR levels.
An adult male with schizophrenia who has been noncompliant in taking oral antipsychotic medications refuses a prescribed IM medication. What action should the nurse take?
- A. Notify the healthcare provider of the client's refusal
- B. Attempt to convince the client to take the medication
- C. Administer the medication without the client's consent
- D. Document the refusal and take no further action
Correct Answer: A
Rationale: The correct action is to notify the healthcare provider of the client's refusal. It is important for the healthcare provider to be informed so that they can decide on the next steps in the client's treatment, which may involve exploring alternative options or strategies. Attempting to convince the client to take the medication may not be effective, especially if the client is refusing. Administering the medication without the client's consent would violate the client's autonomy and rights. Simply documenting the refusal without further action may not address the client's treatment needs.
The nurse is triaging several children as they present to the emergency room after an accident. Which child requires the most immediate intervention by the nurse?
- A. An 11-year-old with a headache, nausea, and projectile vomiting
- B. A 5-year-old with a broken arm
- C. A 7-year-old with minor abrasions
- D. A 9-year-old with a twisted ankle
Correct Answer: A
Rationale: The correct answer is A. Projectile vomiting in a child with a headache could indicate increased intracranial pressure, requiring immediate attention. Choices B, C, and D do not present with symptoms indicating potentially life-threatening conditions that require urgent intervention.