Nokea
The nurse is caring for the client with a large, open sternal wound resulting from a burn injury. The client is receiving enteral feeding, Oxepa (an anti-inflammatory, pulmonary 1.5 Cal/mL formula), at 25 mL/hour. Which laboratory value finding best indicates that the client is receiving inadequate nutrition?
- A. Phosphorus
- B. Platelets
- C. Prealbumin
- D. Potassium
Correct Answer: C
Rationale: Prealbumin is used to evaluate nutritional status. A low level of prealbumin indicates inadequate nutrition. Prealbumin has a half-life of 2 days and reflects changes in serum protein stores more rapidly than other indices. The phosphorus level decreases in malnutrition as well as other conditions, but this is not the best indicator of inadequate nutrition. Platelets are essential to blood clotting and may or may not be altered with inadequate nutrition. Potassium is the major cation within the cell and may be low due to renal failure or GI disorders.
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Which of the following terms would the eye clinic nurse use to document that a client has nearsightedness?
- A. Presbyopia
- B. Amblyopia
- C. Hyperopia
- D. Myopia
Correct Answer: D
Rationale: Myopia is the medical term for nearsightedness, where distant objects appear blurry.
The client mentions all of the following to the nurse. Which of the following should the client be encouraged to report to the physician immediately?
- A. A small mole on the right thigh that has looked the same ever since the client can remember
- B. A pigmented area that is pink-red in color and has been present since birth
- C. Three small warts on the right hand that have been present for some time
- D. A black and purple mole that is growing larger and has a funny shape
Correct Answer: D
Rationale: A growing, irregularly shaped, and discolored mole may indicate melanoma, requiring immediate medical evaluation.
The nurse is developing a plan of care for a client diagnosed with left-sided paralysis secondary to a right-sided cerebrovascular accident (stroke). Which should be included in the interventions?
- A. Use a pillow to keep the heels off the bed when supine.
- B. Order a low air-loss therapy bed immediately.
- C. Prepare to insert a nasogastric feeding tube.
- D. Order an occupational therapy consult for strength training.
Correct Answer: A
Rationale: Heel elevation prevents pressure ulcers in paralyzed clients. Low air-loss beds require HCP orders, NG tubes are premature, and OT is for rehabilitation, not immediate care.
The nurse is preparing to irrigate the student's eye. What steps are appropriate in completing the irrigation? Select all that apply.
- A. The use the solution directly into the center of the eye.
- B. Tilt the head toward the opposite eye.
- C. Perform hand hygiene and put on gloves.
- D. Offer the client a paper tissue.
- E. Place the solution into the conjunctival sac.
- F. Continue eye irrigations until all redness is resolved.
Correct Answer: C,E
Rationale: Hand hygiene and gloves prevent infection, and placing the solution in the conjunctival sac ensures effective irrigation without damaging the cornea.
The nurse is caring for clients in a long-term care facility. Which is a modifiable risk factor for the development of pressure ulcers?
- A. Constant perineal moisture.
- B. Ability of the clients to reposition themselves.
- C. Decreased elasticity of the skin.
- D. Impaired cardiovascular perfusion of the periphery.
Correct Answer: A
Rationale: Perineal moisture is modifiable through hygiene and barriers, reducing ulcer risk. Repositioning ability, skin elasticity, and perfusion are less modifiable.