Nokea
The nurse is reviewing labs on a group of adult clients. Which lab value would prompt the nurse to immediately notify the health care provider?
- A. hemoglobin 4.8 g/dL
- B. troponin T 0.04 ng/mL
- C. phosphorus 3.8 mg/dL
- D. bilirubin (total) 0.7 mg/dL
Correct Answer: A
Rationale: Hemoglobin of 4.8 g/dL is critically low, indicating severe anemia and requiring immediate provider notification. Other values are normal or near-normal.
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Which assessment finding in a client with COPD indicates to the nurse that the respiratory problem is chronic?
- A. Wheezing on exhalation
- B. Productive cough
- C. Clubbing of fingers
- D. Cyanosis
Correct Answer: C
Rationale: Clubbing of fingers is a sign of chronic hypoxia, indicative of long-standing COPD, unlike wheezing or cough, which can occur in acute or chronic stages.
The client has an order for FeSO4 liquid. Which method of administration would be best?
- A. Administer the medication with milk
- B. Administer the medication with a meal
- C. Administer the medication with orange juice
- D. Administer the medication undiluted
Correct Answer: C
Rationale: Administering FeSO4 with orange juice enhances iron absorption due to its vitamin C content.
The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:
- A. The client is at risk for evisceration
- B. The client will require frequent dressing changes
- C. The straps provide support for drains that are inserted into the incision
- D. No sutures or clips are used to secure the incision
Correct Answer: B
Rationale: Montgomery straps are used to secure dressings in a way that allows for frequent changes without removing adhesive, which is common after a cholecystectomy due to drainage or wound care needs.
The '5 A's' of smoking cessation intervention begin with which of the following?
- A. Advise all clients who smoke to stop smoking.
- B. Ask all clients about tobacco use at every visit.
- C. Assess clients' willingness to stop smoking.
- D. Assist the client to stop smoking.
Correct Answer: B
Rationale: The 5 A's begin with Ask (B), identifying tobacco use at every visit, followed by Advise, Assess, Assist, and Arrange.
A client with otosderosis is scheduled for a stapedectomy. Which finding suggests a complication involving the seventh cranial nerve?
- A. Diminished hearing
- B. Sensation of fullness in the ear
- C. Inability to move the tongue side to side
- D. Changes in facial sensation
Correct Answer: D
Rationale: The seventh cranial (facial) nerve controls facial movements and sensation; changes in facial sensation post-stapedectomy suggest nerve involvement.