Nokea
The nurse is reviewing the lab results of four clients. Which finding should be reported to the physician?
- A. A client with chronic renal failure with a serum creatinine of 5.6 mg/dL
- B. A client with rheumatic fever with a positive C reactive protein
- C. A client with gastroenteritis with a hematocrit of 52%
- D. A client with epilepsy with a white cell count of 3,800 mm³
Correct Answer: C
Rationale: A hematocrit of 52% in gastroenteritis suggests dehydration, which requires immediate reporting.
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The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
- A. Replenish his supply every 3 months
- B. Take one every 15 minutes if pain occurs
- C. Leave the medication in the brown bottle
- D. Crush the medication and take with water
Correct Answer: C
Rationale: Nitroglycerin should be stored in its original brown bottle to protect it from light and maintain potency.
The client with color blindness will most likely have problems distinguishing which of the following colors?
- A. Orange
- B. Violet
- C. Red
- D. White
Correct Answer: C
Rationale: Red-green color blindness is the most common type, making it difficult to distinguish red.
While caring for a client with cervical cancer, the nurse notes that the radioactive implant is lying in the bed. The nurse should:
- A. Place the implant in a biohazard bag and return it to the lab
- B. Give the client a pair of gloves and ask her to reinsert the implant
- C. Use tongs to pick up the implant and return it to a lead-lined container
- D. Discard the implant in the commode and double-flush
Correct Answer: C
Rationale: Radioactive implants must be handled with tongs and placed in a lead-lined container to minimize radiation exposure, per safety protocols.
The charge nurse is making an assignment for an LPN on an upcoming shift. Which assignment would be appropriate?
- A. a client with a recent head injury and active seizures
- B. a post-operative patient requiring vital sign monitoring every hour
- C. a post-operative patient receiving a blood transfusion
- D. a client with diabetes requiring discharge instruction on insulin injection
Correct Answer: B
Rationale: Vital sign monitoring is within the LPN’s scope. Seizure management, blood transfusions, and discharge teaching require RN expertise.
The nurse is assigned to work with the parents of a retarded child. Which of the following should the nurse include in the care plan for the parents?
- A. Interpret the grieving process for the parents.
- B. Discuss the reality of institutional placement.
- C. Assist the parents in making decisions and long-term plans for the child.
- D. Perform a family assessment to assist in the planning of intervention.
Correct Answer: D
Rationale: assessment, this will help the nurse to know where the family is in regard to grieving, coping, etc.