Nokea
The nurse is reviewing the lab reports on several clients. Which one should be reported to the physician immediately?
- A. A serum creatinine of 5.2 mg/dL in a client with chronic renal failure
- B. A positive C reactive protein in a client with rheumatic fever
- C. A hematocrit of 52% in a client with gastroenteritis
- D. A white cell count of 2,200 cu/mm in a client taking Dilantin phenytoin
Correct Answer: D
Rationale: A white cell count of 2,200 cu/mm indicates severe leukopenia, a serious side effect of Dilantin, requiring immediate reporting.
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A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should:
- A. Serve high-calorie foods she can carry with her
- B. Encourage her appetite by sending out for her favorite foods
- C. Serve her small, attractively arranged portions
- D. Allow her in the unit kitchen for extra food whenever she pleases
Correct Answer: A
Rationale: High-calorie, portable foods accommodate the restlessness and distractibility of mania, ensuring adequate nutrition.
An older man is seen in the outpatient clinic for treatment of an acute attack of gout. Which of the following nursing interventions would be MOST beneficial in decreasing the client’s pain during ambulation?
- A. Perform passive range-of-motion exercises before walking.
- B. Encourage partial weight bearing while ambulating.
- C. Immobilize the extremity between activities.
- D. Restrict the amount of time and the distance the man walks.
Correct Answer: B
Rationale: would relieve weight, pressure, and stress on affected leg, may use walker
A 28-year-old woman pregnant with twins comes in for her prenatal appointment. She tells the nurse that she has two children at home (ages 4 years and 16 months), and she had one abortion 6 years ago when she was 8 weeks along in the pregnancy. The nurse charts
- A. gravida 4, para 2.
- B. gravida 4, para 3.
- C. gravida 5, para 2.
- D. gravida 5, para 3.
Correct Answer: C
Rationale: Gravida counts all pregnancies (2 children, 1 abortion, current twin pregnancy = 5). Para counts deliveries after 20 weeks (2 children = 2). Twins count as one delivery.
The most appropriate means of rehydration of a 7-month-old with diarrhea and mild dehydration is:
- A. Oral rehydration therapy with an electrolyte solution
- B. Replacing milk-based formula with a lactose-free formula
- C. Administering intraveneous Dextrose 5% 1/4 normal saline
- D. Offering bananas, rice, and applesauce along with oral fluids
Correct Answer: A
Rationale: Oral rehydration therapy with electrolyte solutions is the standard for mild dehydration in infants, as it effectively restores fluid and electrolyte balance.
The nursing assistant is taking vitals for a client on mechanical ventilation. Which of the following findings should the nursing assistant report to the nurse immediately?
- A. respiratory rate 26 breaths/minute
- B. heart rate 82 beats/minute
- C. blood pressure 152/86 mmHg
- D. temperature 102.1°F
Correct Answer: D
Rationale: Fever (102.1°F) in a ventilated client suggests infection (e.g., ventilator-associated pneumonia), requiring immediate reporting.