Nokea
The nurse reviews new laboratory results for assigned clients. Which finding is the priority for the nurse to report to the supervising registered nurse?
- A. CD4+ cell count of 600 cells/uL in a client with HIV and oral candidiasis who is receiving PO fluconazole
- B. Hemoglobin A1c of 7.3% in a client with type 2 diabetes and pneumonia who is receiving IV levofloxacin heparin infusion
- C. Serum glucose of 65 mg/dL (3.61 mmol/L) in a client with radiation enteritis who is receiving total parenteral nutrition
Correct Answer: C
Rationale: A serum glucose of 65 mg/dL indicates hypoglycemia, which is critical in a client on total parenteral nutrition, as it may require immediate adjustment of glucose infusion or administration of dextrose.
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The nurse is walking through a crowded waiting room when the respiratory therapist approaches the nurse and asks, 'How is the client in room 312?' Which of the following responses would be most appropriate for the nurse to make?
- A. I will document my most recent assessment in the client's medical record for your review.
- B. Additional medications were prescribed to help improve the client's respiratory status.
- C. The client was doing much better when I last checked during hourly rounds.
- D. We need to move away from this area to discuss the client's status.
Correct Answer: D
Rationale: Discussing client information in a crowded area risks breaching confidentiality. Moving to a private area ensures compliance with HIPAA and protects client privacy.
The nurse has been interacting for several weeks with a client on the psychiatric unit. The nurse is to be transferred to another unit. Which comment by the client indicates separation anxiety?
- A. We had a good time at the party last night. You should have been here.'
- B. Some of us are going to the museum next week. Too bad you can't go.'
- C. I was thinking about my friend last night; the one who died in the car crash.'
- D. I was telling my wife what a good nurse you are.'
Correct Answer: B
Rationale: Expressing regret about the nurse missing a future event suggests attachment and anxiety about the nurse's departure, indicating separation anxiety. Other comments lack this emotional connection.
The nurse in a long-term care facility observes a nursing assistant caring for a resident who has a hearing aid and dentures. Which action by the nursing assistant should be corrected?
- A. The nursing assistant places a washcloth in the sink before brushing the client's dentures.
- B. The nursing assistant uses toothpaste to clean the dentures.
- C. The nursing assistant uses alcohol to wipe off the exterior of the hearing aid.
- D. The nursing assistant wipes the exterior of the hearing aid with a damp cloth.
Correct Answer: C
Rationale: The exterior of a hearing aid should be wiped regularly with a damp cloth. Alcohol should not be used as it can damage the device. The nursing assistant should place a washcloth in the sink before brushing dentures to protect them if dropped. Toothpaste is appropriate to clean dentures.
The nurse is collecting data from a client at 15 weeks gestation who has hyperemesis gravidarum. Which of the following findings would be consistent with the condition?
- A. decreased urine specific gravity
- B. blood pressure >=140/90 mm Hg
- C. urinalysis positive for ketones
- D. bradycardia
Correct Answer: C
Rationale: Hyperemesis gravidarum causes severe vomiting, leading to dehydration and starvation, resulting in ketosis. Positive ketones in urinalysis confirm this metabolic state.
A client has just been diagnosed with diabetes and is admitted for insulin regulation. The client asks the nurse, 'Why do I need to be stuck so many times per day?' Which of the following statements best explains the rationale for checking the client's blood glucose level frequently?
- A. Blood glucose levels need to be checked every hour to ensure constant insulin needs.'
- B. Any fluctuation in blood glucose levels must be avoided.'
- C. Blood glucose levels are checked to be able to adjust the dosage of your insulin.'
- D. Elevations in glucose can result in alkalosis.'
Correct Answer: C
Rationale: Frequent blood glucose checks allow for insulin dose adjustments to maintain glycemic control. Hourly checks are excessive, fluctuations are managed not avoided, and alkalosis is unrelated to glucose elevations.