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Which diagnostic data should be reported to the health-care provider (HCP) immediately?
- A. The ABG result of pH 7.11, PaCO2 45, HCO3 20, and PaO2 98 for a client diagnosed with type 1 diabetes.
- B. Sodium 137 mEq/L, potassium 4 mEq/L, glucose 120 mg/dL for a client diagnosed with gastroenteritis.
- C. Hemoglobin 9.4 g/dL and hematocrit 29% for a client who received a blood transfusion on the previous shift.
- D. A pulse oximetry reading of 93% for a client diagnosed with chronic obstructive pulmonary disease (COPD).
Correct Answer: A
Rationale: A pH of 7.11 indicates severe acidosis (likely DKA in type 1 diabetes), requiring immediate HCP notification. Normal electrolytes, post-transfusion anemia, and COPD oximetry are less urgent.
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Which priority teaching information should the nurse discuss with the client to help prevent contracting hepatitis B?
- A. Explain the importance of good hand washing.
- B. Recommend the client take the hepatitis B vaccine.
- C. Tell the client not to ingest unsanitary food or water.
- D. Discuss how to implement Standard Precautions.
Correct Answer: B
Rationale: The hepatitis B vaccine is the most effective way to prevent hepatitis B, a bloodborne virus. Handwashing and food safety are less relevant, and Standard Precautions are for healthcare settings.
The client tells the nurse about being diagnosed with a 2-cm cancerous tumor in the liver. The client wants to know about the treatment. Which statement should be the basis for the nurse’s response?
- A. The use of chemotherapy is the first-line treatment for liver cancer.
- B. Liver transplantation is not an option for clients with liver cancer.
- C. Radiofrequency ablation can be successful in treating tumors of this size.
- D. A tumor of this size can only be removed through an open surgical approach.
Correct Answer: C
Rationale: A. Chemotherapy is only used for clients who are not likely to benefit from other therapies. B. Liver transplantation is used when the tumor is large or localized. C. Radiofrequency ablation is a treatment technique that uses high-frequency alternating electrical current to heat tissue cells and destroy them. It can be successfully used to treat tumors less than 5 cm in size because these tumors tend to be slow growing and encapsulated. D. Surgical resection of the tumor is used when the tumor is large or localized.
The client diagnosed with gastroenteritis is being discharged from the emergency department. Which intervention should the nurse include in the discharge teaching?
- A. If diarrhea persists for more than 96 hours, contact the health-care provider.
- B. Instruct the client to wash hands thoroughly before handling any type of food.
- C. Explain the importance of decreasing steroids gradually as instructed.
- D. Discuss how to collect all stool samples for the next 24 hours.
Correct Answer: B
Rationale: Handwashing prevents the spread of gastroenteritis, a key discharge teaching point. Persistent diarrhea is concerning but less specific, steroids are irrelevant, and stool collection is not routine.
Which statement indicates to the emergency department nurse the client diagnosed with acute gastroenteritis understands the discharge teaching?
- A. I will probably have some leg cramps while I have gastroenteritis.
- B. I should decrease my fluid intake until the diarrhea subsides.
- C. I should reintroduce solid foods very slowly back into my diet.
- D. I should only drink bottled water until the abdominal cramping stops.
Correct Answer: C
Rationale: Slowly reintroducing solid foods prevents GI irritation, indicating understanding of gastroenteritis recovery. Leg cramps are possible but not emphasized, and decreasing fluids or bottled water is incorrect.
The nurse is caring for clients in an outpatient clinic. Which information should the nurse teach regarding the American Cancer Society's recommendations for the early detection of colon cancer?
- A. Beginning at age 60, a digital rectal examination should be done yearly.
- B. After reaching middle age, a yearly fecal occult blood test should be done.
- C. Have a colonoscopy at age 50 and then once every five (5) to 10 years.
- D. A flexible sigmoidoscopy should be done yearly after age 40.
Correct Answer: C
Rationale: The American Cancer Society recommends a colonoscopy starting at age 45–50, then every 5–10 years for average-risk individuals, as it effectively detects polyps and cancer. Other options are outdated or incorrect.