Nokea
Laboratory Reference Ranges
Creatinine
Male: 0.6–1.3 mg/dL
(53–114.9 μmol/L)
Female: 0.5–1.2 mg/dL
(44.2–106.1 μmol/L)
The nurse is planning to assess 4 assigned clients. Which client situation is of greatest concern and warrants immediate assessment?
- A. Client scheduled for hemodialysis in an hour who has a serum creatinine level of 9.2 mg/dL (813 µmol/L) and refuses to take prescribed medications
- B. Client taking diphenhydramine for urticaria who reports difficulty urinating and increasing lower abdominal pain
- C. Client with an infected venous leg ulcer prescribed IV vancomycin who has a dressing saturated with yellow, foul-smelling drainage
- D. Client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting
Correct Answer: D
Rationale: Severe pain (10/10) with bloating, nausea, and vomiting in an inguinal hernia suggests strangulation, a surgical emergency. High creatinine, urinary retention, and infected ulcers are urgent but less immediately life-threatening.
You may also like to solve these questions
What information would be most important for the nurse to obtain from a client with suspected bladder cancer who reports blood in the urine but no associated pain?
- A. Family history
- B. Industrial chemical exposure
- C. Tobacco use
- D. Usual diet
Correct Answer: C
Rationale: Tobacco use is the strongest risk factor for bladder cancer, strongly linked to painless hematuria. Chemical exposure is relevant but less common, family history is weak, and diet is not a primary factor.
The nurse is to administer a tuberculin skin test. At what angle should the needle be inserted?
- A. A 10-degree angle
- B. A 30-degree angle
- C. A 60-degree angle
- D. A 90-degree angle
Correct Answer: A
Rationale: A 10-degree angle ensures intradermal injection for a tuberculin skin test, creating a wheal for accurate reading.
The nurse is caring for a newborn who has a cleft palate. Which of the following actions should the nurse take to promote oral intake? Select all that apply.
- A. Use specialty bottles or nipples
- B. Burp the newborn often when feeding
- C. Feed the newborn in an upright position
- D. Initiate feeding as soon as possible after birth
- E. Encourage the mother to exclusively breastfeed
Correct Answer: A,B,C
Rationale: Specialty bottles, frequent burping, and upright positioning facilitate feeding and reduce aspiration risk in cleft palate. Early feeding is appropriate but not specific, and exclusive breastfeeding is often challenging.
The nurse has taught the parent of a 6-year-old client with bacterial conjunctivitis how to administer ophthalmic medications. Which of the following statements by the parent would indicate a correct understanding of the teaching?
- A. My child should look down at the floor while I administer the eye drops.
- B. My child should squeeze the eyes closed after I administer the eye drops.
- C. I will apply firm pressure to my child's eyes after I administer the eye ointment
- D. I will apply the eye ointment along my child's lower eyelids starting at the inner corner of the eyes
Correct Answer: D
Rationale: Appropriate administration of ophthalmic medications (eg, eye drops, ointments) protects eye structures and ensures appropriate distribution across the eye. Ophthalmic ointment should be administered along the lower eyelid, moving from the inner canthus to the outer canthus (inner corner to outer corner) (Option 4). In addition, the medication package (eg, eye dropper, tube of ointment) must not touch the eyes to prevent contamination.
Which nursing intervention is most critical during the administration of Acyclovir (Zovirax)?
- A. Limit the client's activity.
- B. Encourage a high-carbohydrate diet.
- C. Utilize an incentive spirometer to improve respiratory function.
- D. Encourage fluids.
Correct Answer: D
Rationale: Acyclovir can cause renal toxicity; encouraging fluids promotes renal perfusion and reduces risk of crystal formation in the kidneys.