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Which client's laboratory value requires immediate intervention by a nurse?
- A. A client with GI bleeding who is receiving a blood transfusion and has a hemoglobin of 7 grams.
- B. A client with pancreatitis who has a fasting glucose of 190 mg/dl today and had 160 mg/dl yesterday.
- C. A client with hepatitis who is jaundiced and has a bilirubin level that is 4 times the normal value.
- D. A client with cancer who has an absolute neutrophil count < 500 today and had 2,000 yesterday.
Correct Answer: D
Rationale: The correct answer is D because a client with an absolute neutrophil count < 500 is at high risk for serious infections due to severe neutropenia. Neutrophils are crucial for fighting infections, and a low count puts the client at immediate risk. Therefore, intervention is required to prevent life-threatening complications.
Choice A: A hemoglobin of 7 grams in a client with GI bleeding receiving a blood transfusion indicates anemia, but it does not require immediate intervention unless the client is symptomatic.
Choice B: A fasting glucose of 190 mg/dl in a client with pancreatitis is elevated but does not require immediate intervention unless the client is symptomatic or experiencing complications.
Choice C: A bilirubin level 4 times the normal value in a jaundiced client with hepatitis is concerning but does not require immediate intervention unless there are signs of severe liver dysfunction or complications.
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An elderly client with congestive heart failure (CHF) is admitted to the hospital. Which laboratory test result should the nurse expect to find?
- A. Elevated serum sodium level.
- B. Decreased brain natriuretic peptide (BNP) level.
- C. Increased serum creatinine level.
- D. Elevated hemoglobin and hematocrit levels.
Correct Answer: C
Rationale: The correct answer is C, increased serum creatinine level. In CHF, the heart's reduced pumping ability can lead to decreased blood flow to the kidneys, resulting in impaired kidney function. This can cause an elevation in serum creatinine level, indicating decreased kidney function. Elevated serum sodium level (A) is not typically seen in CHF, as patients often have fluid retention leading to dilutional hyponatremia. Decreased BNP level (B) is not expected in CHF, as BNP is released in response to increased ventricular stretching and volume overload. Elevated hemoglobin and hematocrit levels (D) are not directly related to CHF; they may be seen in conditions like dehydration or chronic hypoxia, but not specifically in CHF.
An elderly male client reports to the clinic nurse that he is experiencing increasing nocturia with difficulty initiating his urine stream. He reports a weak urine flow and frequent dribbling after voiding. Which nursing action should be implemented?
- A. Obtain a urine specimen for culture and sensitivity.
- B. Encourage the client to schedule a digital rectal exam.
- C. Advise the client to maintain a voiding diary for one week.
- D. Instruct the client in effective techniques for cleansing the glans penis.
Correct Answer: B
Rationale: The correct answer is B: Encourage the client to schedule a digital rectal exam. This option is correct because the client's symptoms of nocturia, weak urine flow, and difficulty initiating urine stream suggest potential prostate issues, such as benign prostatic hyperplasia (BPH). A digital rectal exam can help assess the size and condition of the prostate gland. It is an essential step in diagnosing BPH or other prostate conditions.
Other choices are incorrect because:
A: Obtaining a urine specimen for culture and sensitivity is not the priority in this case, as the client's symptoms are more indicative of a prostate issue rather than a urinary tract infection.
C: Maintaining a voiding diary may provide information on the frequency and volume of urine output, but it does not address the underlying cause of the client's symptoms.
D: Instructing the client in cleansing techniques for the glans penis is not relevant to the reported symptoms and does not address the potential prostate issue.
A client diagnosed with major depressive disorder refuses to get out of bed, eat, or participate in group therapy. Which intervention is most important for the nurse to implement?
- A. Offer the client high-calorie snacks and frequent small meals.
- B. Ask the client why they are not participating in therapy.
- C. Sit with the client and offer support without demanding participation.
- D. Encourage the client to discuss their feelings of hopelessness.
Correct Answer: C
Rationale: The correct answer is C because sitting with the client and offering support without demanding participation is crucial in building trust and rapport. This approach respects the client's autonomy and allows them to feel supported without pressure. It also creates a safe space for the client to open up when they are ready.
Explanation for why the other choices are incorrect:
A: Offering high-calorie snacks and frequent small meals does not address the core issue of the client's refusal to participate in therapy.
B: Asking the client why they are not participating in therapy may come off as confrontational and could further discourage them from opening up.
D: Encouraging the client to discuss their feelings of hopelessness may be overwhelming for them at this stage and could lead to resistance.
A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse?
- A. Is unable to feel sensation in the arms and hands.
- B. Has flaccid upper and lower extremities.
- C. Blood pressure is 110/70 and the apical pulse is 68.
- D. Respirations are shallow, labored, and 14 breaths/minute.
Correct Answer: D
Rationale: The correct answer is D because shallow, labored respirations at 14 breaths/minute indicate potential respiratory distress in a client with a C-5 spinal cord injury. This level of injury compromises the function of the diaphragm and intercostal muscles, leading to impaired respiratory effort. Immediate intervention is crucial to prevent respiratory failure and subsequent complications. Choices A and B are common findings in clients with spinal cord injuries and do not require immediate intervention. Choice C indicates stable vital signs within normal range, which do not necessitate immediate action.
What action should the healthcare provider take to reduce the risk of vesicant extravasation in a client receiving intravenous chemotherapy?
- A. Administer an antiemetic before starting the chemotherapy.
- B. Instruct the client to drink plenty of fluids during the treatment.
- C. Keep the head of the bed elevated until the treatment is completed.
- D. Monitor the client's intravenous site hourly during the treatment.
Correct Answer: D
Rationale: The correct answer is D: Monitor the client's intravenous site hourly during the treatment. This is crucial to reduce the risk of vesicant extravasation, which can cause tissue damage if the chemotherapy leaks into the surrounding tissues. By monitoring the IV site hourly, the healthcare provider can detect any signs of infiltration or extravasation early and take necessary actions to prevent further harm.
A: Administering an antiemetic before starting chemotherapy is unrelated to preventing vesicant extravasation.
B: Instructing the client to drink plenty of fluids does not directly address the risk of vesicant extravasation.
C: Keeping the head of the bed elevated is not specific to preventing vesicant extravasation and may not effectively reduce the risk.