Nokea
The nurse is caring for assigned clients and is reviewing laboratory data. Which laboratory data requires follow-up? A client with a
- A. serum total cholesterol 180 mg/dl (4.65 mmol/L)
- B. glycosylated hemoglobin (A1C) 7.5%
- C. serum calcium 9.2 mg/dl (2.30 mmol/L)
- D. serum creatinine 1.0 mg/dL (88.4 µmol/L)
Correct Answer: B
Rationale: An A1C of 7.5% is elevated for a client with diabetes mellitus (DM), as the target is typically ≤7%. This requires follow-up to assess glycemic control.
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The nurse is reviewing newly prescribed medications for assigned clients. Which of the following prescribed medications should the nurse question?
- A. Levothyroxine for a client with a myxedema coma
- B. Hydrochlorothiazide for a client with hyperparathyroidism
- C. Hydrocortisone for a client with adrenal insufficiency
- D. Regular insulin for a client with diabetic ketoacidosis
Correct Answer: B
Rationale: Hydrochlorothiazide can worsen hypercalcemia in hyperparathyroidism and should be questioned.
A nurse is working on discharging a client when the client expresses interest in becoming an organ donor. Which action by the nurse best facilitates the organ donation process?
- A. Providing the client with information about how to register as an organ donor.
- B. Advising the client to sign an organ donor card and carry it with them at all times.
- C. Scheduling the client for immediate organ donation surgery upon expressing interest.
- D. Assisting the client in completing advance directives specifying their wish for organ donation.
Correct Answer: A
Rationale: Providing information on how to register as an organ donor is the most effective way to facilitate the process.
The following scenario applies to the next 1 items
The nurse in the obstetrics department is caring for a 29-year-old primigravida client.
Item 1 of 1
History and Physical
2300: Client is a primigravida at 33 weeks gestation, who awoke to moderate bright red vaginal bleeding. She reports noticing light spotting earlier in the day, which she dismissed as benign. She denies abdominal pain, cramping, or contractions. Her pregnancy has been uncomplicated until recently. She reports increased fetal movement over the last 48 hours. One week ago, she presented to the ED with fever, fatigue, and body aches, and was diagnosed with influenza A. She was treated supportively and discharged home with hydration instructions. Over the past 24 hours, she has experienced nasal congestion and fatigue.
Four days ago, a transabdominal ultrasound showed:
• Fetus in cephalic position
• Normal amniotic fluid volume
Exam findings
• Abdomen: Soft, non-tender
• No uterine contractions noted on palpation
• Moderate amount of dried bright red blood was seen on the undergarments
• 1+ pedal edema
• Peripheral pulses 2+
•
Diagnostics
2342: Fetal Heart Rate (FHR): 144 bpm, moderate variability, no decelerations
Vital Signs
• Temperature: 99.5°F (37.5°C)
• HR 88 bpm
• BP 137/78 mmHg
• RR 18/min
• Pulse oximetry 98% on room air
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
- A. Request a prescription for indomethacin, Prepare the client for a transvaginal ultrasound, Place the client in the lithotomy position for a manual cervical exam, Establish a peripheral vascular access device, Place the client in a room with monitored negative airflow
- B. Placental abruption, Preeclampsia, Placenta previa, Influenza recurrence
- C. Fetal heart rate pattern, Pedal edema, Amount and color of vaginal bleeding, Temperature, Nasal congestion and fatigue level
Correct Answer: C (placenta previa), A (prepare for transvaginal ultrasound, establish peripheral vascular access device), C (fetal heart rate pattern, amount and color of vaginal bleeding)
Rationale: Moderate bright red vaginal bleeding without pain at 33 weeks suggests placenta previa. Transvaginal ultrasound confirms the diagnosis, peripheral access prepares for potential intervention, and monitoring fetal heart rate and bleeding assesses progress.
The nurse is caring for a client who has developed retinal detachment. Which of the following actions should the nurse take first?
- A. Instruct the client to restrict activity
- B. Establish a vascular access device
- C. Review the client's current medications
- D. Educate the client about topical eye ointments
Correct Answer: A
Rationale: Restricting activity is the first priority to prevent further retinal damage.
The nurse is preparing to administer prescribed intravenous phenytoin to a client with epilepsy. Prior to starting the infusion, the nurse should
- A. establish continuous cardiac monitoring
- B. obtain the serum peak level prior to infusion
- C. initiate continuous electroencephalography (EEG) monitoring
- D. insert an indwelling urinary catheter
Correct Answer: A
Rationale: Phenytoin can cause cardiac arrhythmias, so continuous cardiac monitoring is necessary during infusion.