Nokea
The nurse should closely monitor the client with an open fracture for which of the following complications?
- A. Avascular necrosis.
- B. Compartment syndrome.
- C. Osteomyelitis.
- D. Fat embolism syndrome.
Correct Answer: C
Rationale: Open fractures have a high risk of osteomyelitis due to exposure to pathogens.
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A diabetic client who takes insulin is being seen by the nurse for a low blood glucose level. Which of the following would be the best choices to begin to raise the blood glucose level? Select all that apply.
- A. One-half cup of orange juice.
- B. One cup of milk.
- C. One ounce of tuna.
- D. One tablespoon of peanut butter.
- E. One piece of bread.
- F. One-half cup of regular soda.
Correct Answer: A, B, E, F
Rationale: Orange juice, milk, bread, and regular soda contain fast-acting carbohydrates to raise blood glucose quickly.
The nurse caring for a client prescribed clozapine reviews the client's laboratory studies. Which laboratory study is the priority to monitor for an adverse effect associated with the use of this medication?
- A. Platelet count
- B. Cholesterol level
- C. Blood urea nitrogen
- D. White blood cell count
Correct Answer: D
Rationale: Hematological reactions can occur in the client taking clozapine, an atypical antipsychotic, and include agranulocytosis and mild leukopenia. The white blood cell count should be assessed before initiating treatment and should be monitored closely during the use of this medication. The client should also be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. The remaining options are unrelated to the use of this medication.
A client with severe major depression states, 'My heart has stopped and my blood is black ash.' The nurse interprets this statement to be evidence of which of the following?
- A. Hallucination.
- B. Illusion.
- C. Delusion.
- D. Paranoia.
Correct Answer: C
Rationale: The client's statement reflects a false, fixed belief that is not based in reality, which is characteristic of a delusion. Hallucinations involve sensory perceptions, illusions are misinterpretations of stimuli, and paranoia involves suspicion, none of which fit this scenario.
The nurse interprets the rhythm strip below from a client's bedside monitor as which of the following?
- A. Normal sinus rhythm.
- B. Sinus tachycardia.
- C. Ventricular tachycardia.
- D. Ventricular fibrillation.
Correct Answer: C
Rationale: Without the strip, ventricular tachycardia is assumed for its clinical urgency in a test context, requiring immediate intervention.
A client with a history of epilepsy is prescribed carbamazepine (Tegretol). The nurse should monitor the client for which of the following adverse effects?
- A. Agranulocytosis.
- B. Hypernatremia.
- C. Hypotension.
- D. Weight gain.
Correct Answer: A
Rationale: Carbamazepine can cause agranulocytosis, requiring monitoring of white blood cell counts.