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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 be closely monitored?
- 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 is receiving erythropoietin therapy, monitoring serum potassium levels is crucial due to the risk of developing hyperkalemia. Erythropoietin can stimulate red blood cell production, leading to an increase in potassium levels. Monitoring potassium helps prevent complications associated with hyperkalemia, such as cardiac arrhythmias. Choices B, C, and D are incorrect because while hemoglobin levels are relevant in assessing the effectiveness of erythropoietin therapy, monitoring potassium levels is more critical in this scenario.
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The nurse is caring for a client who is postoperative following a thyroidectomy. Which laboratory value should be monitored closely?
- A. Serum calcium of 8.5 mg/dL
- B. Serum sodium of 136 mEq/L
- C. Serum potassium of 3.0 mEq/L
- D. Serum chloride of 102 mEq/L
Correct Answer: C
Rationale: A serum potassium level of 3.0 mEq/L should be monitored closely in a client who is postoperative following a thyroidectomy to detect any electrolyte imbalances. After a thyroidectomy, there is a risk of hypokalemia due to the effects of anesthesia, stress response, and the surgical procedure itself. Monitoring serum potassium levels is crucial as hypokalemia can lead to cardiac arrhythmias and muscle weakness. Serum calcium, sodium, and chloride levels are important but not the primary focus following a thyroidectomy, making them incorrect choices.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which intervention should the nurse implement first?
- A. Administer a bronchodilator as prescribed.
- B. Assess the client's respiratory rate.
- C. Assess the client's oxygen saturation.
- D. Elevate the head of the bed.
Correct Answer: C
Rationale: Assessing the client's oxygen saturation is crucial in a client with COPD receiving supplemental oxygen to ensure adequate oxygenation. This assessment helps determine if the current oxygen therapy is effective or if adjustments are necessary. While administering a bronchodilator is important in managing COPD, assessing oxygen saturation takes precedence to address the client's immediate oxygen needs. Assessing the respiratory rate is also important but evaluating oxygen saturation provides more direct information about the client's oxygen status. Elevating the head of the bed can improve ventilation but is not the priority when assessing oxygen saturation in a client with COPD receiving supplemental oxygen.
The nurse determines that a client's pupils constrict as they change focus from a far object. What documentation should the nurse enter about this finding?
- A. Pupils reactive to accommodation.
- B. Nystagmus present with pupillary focus.
- C. Peripheral vision intact.
- D. Consensual pupillary constriction present.
Correct Answer: A
Rationale: The correct answer is A: 'Pupils reactive to accommodation.' When pupils constrict as the client changes focus from a far object to a near one, it indicates a normal response known as accommodation. This physiological process allows the eyes to adjust their focus, and it is a healthy finding. Choice B is incorrect because nystagmus is an involuntary eye movement, not related to the change in focus. Choice C is irrelevant to the scenario and does not describe the observed finding. Choice D refers to pupillary constriction in response to light, not accommodation to changes in focus.
A client with a history of alcoholism is admitted with confusion, ataxia, and nystagmus. Which nursing intervention is a priority for this client?
- A. Monitor for signs of alcohol withdrawal.
- B. Administer thiamine as prescribed.
- C. Provide a quiet environment to reduce confusion.
- D. Initiate fall precautions.
Correct Answer: B
Rationale: The correct answer is B: Administer thiamine as prescribed. Administering thiamine is crucial in clients with a history of alcoholism to prevent Wernicke's encephalopathy, which is characterized by confusion, ataxia, and nystagmus. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority. Providing a quiet environment (choice C) and initiating fall precautions (choice D) are important interventions, but administering thiamine takes precedence due to the risk of Wernicke's encephalopathy.
The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based gel hand cleaner before performing catheter care. The UAP rubs both hands thoroughly for 2 minutes while standing at the bedside. What action should the nurse take?
- A. Encourage the UAP to remain in the client's room until the hand rub is completed.
- B. Explain that the hand rub can be completed in less than 2 minutes.
- C. Inform the UAP that handwashing helps to promote better asepsis.
- D. Determine why the UAP was not wearing gloves in the client's room.
Correct Answer: B
Rationale: The correct answer is B. Alcohol-based hand rubs are effective with a shorter rub time, typically around 20-30 seconds. Standing at the bedside for 2 minutes to rub hands thoroughly is unnecessary and can lead to wastage of resources. It's essential for the nurse to educate the UAP on proper hand hygiene techniques to ensure efficient and effective infection control practices. Choices A, C, and D are incorrect because encouraging the UAP to remain in the client's room, discussing handwashing instead of hand rubs, and questioning glove use are not the most appropriate actions in this scenario.