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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A 6-year-old was just diagnosed with pediculosis capitis. Which comment by the mother of the child indicates to the nurse in the physician's office that she does not understand how this condition is spread?
- A. I need to wash all his bed sheets in hot water.'
- B. I will call the school nurse and tell her.'
- C. I think he got this at our neighbor's house; it's very dirty.'
- D. I will tell my son not to wear other children's hats.'
Correct Answer: C
Rationale: Blaming a dirty house misrepresents lice transmission, which occurs via direct head-to-head contact or sharing items, indicating misunderstanding.
The nurse enters the room of a client with dementia and observes the client grimacing while pulling at the indwelling urinary catheter. The nurse notes blood trickling from the urinary meatus and pink-tinged urine in the urinary drainage bag. It would be a priority for the nurse to
- A. obtain a urine specimen for urinalysis
- B. deflate the balloon of the urinary catheter
- C. remove the urinary catheter in a single swift motion
- D. use sterile gauze to absorb the blood around the meatus
Correct Answer: B
Rationale: Blood and grimacing suggest trauma or irritation from the catheter. Deflating the balloon allows safe removal to prevent further injury, pending provider orders.
The home health nurse is caring for a 6-year-old client who has a tracheostomy and is being mechanically ventilated when the ventilator's apnea alarm sounds. The nurse determines the client is unresponsive and pulseless, and there are no other caregivers present. Which of the following actions should the nurse take next?
- A. Deliver 30 chest compressions.
- B. Activate the emergency response system.
- C. Locate an automated external defibrillator.
- D. Deliver 2 breaths using a bag valve device connected to the tracheostomy.
Correct Answer: B
Rationale: Activating the emergency response system ensures rapid assistance for a pulseless child, initiating the chain of survival in pediatric cardiac arrest.
When unlicensed assistive personnel (UAP) assist a client with a chest tube back to bed from the bedside commode, the plastic chest drainage unit accidentally falls over and cracks. The UAP immediately report this incident to the nurse. What is the nurse's immediate action?
- A. Clamp the tube close to the client's chest until a new chest drainage unit is set up
- B. Notify the health care provider
- C. Place the distal end of the chest tube into a bottle of sterile saline
- D. Position the client on the left side
Correct Answer: C
Rationale: Placing the distal end of the chest tube in sterile saline maintains a water seal, preventing air from entering the pleural space until a new drainage unit is prepared.
The nurse is talking with a client who has urge incontinence and is receiving tolterodine. It would require immediate follow-up if the client reports
- A. straining to have a bowel movement
- B. going an entire workday without needing to urinate
- C. using over-the-counter artificial saliva products for dry mouth
- D. experiencing occasional dizziness in the morning and with position changes
Correct Answer: B
Rationale: Not urinating for an entire workday suggests urinary retention, a serious side effect of tolterodine, requiring immediate evaluation to prevent bladder damage.