Which of the following laboratory values requires immediate follow-up?
- A. phenytoin level of 8 mcg/mL (32 mcmol/L) for a client who is receiving enteral feedings
- B. digoxin level of 1.3 ng/mL (1.7 nmol/L) for a client who has a heart rate of 62/min
- C. lithium level of 0.8 mEq/L (0.8 mmol/L) for a client who is reporting a decreased appetite
- D. International normalized ratio (INR) of 3 for a client who has a prosthetic aortic valve
Correct Answer: A
Rationale: Phenytoin levels of 8 mcg/mL are subtherapeutic (therapeutic range: 10-20 mcg/mL), especially with enteral feedings that reduce absorption, requiring immediate adjustment.
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The client has a chest tube attached to a portable water seal drainage system. Four hours after the chest tube is inserted, the nurse notes that there is no bubbling in the water seal compartment. What is the most likely explanation for this?
- A. The lung has reexpanded.
- B. There is an obstruction in the tubing coming from the pleural cavity.
- C. There is an air leak in the drainage system.
- D. The suction is not turned on.
Correct Answer: A
Rationale: No bubbling in the water seal four hours post-insertion suggests the lung has reexpanded, resolving the pneumothorax. Obstruction, air leaks, or inactive suction would typically cause other signs.
A nurse is planning to complete a physical examination of a toddler. Which approach is an appropriate intervention by the nurse?
- A. Encourage the parent to be involved with the child
- B. Engage in physical contact by removing the toddler's outer clothing first
- C. Have medical equipment lying on a counter within view
- D. Perform an examination in a head-to-toe order
Correct Answer: A
Rationale: Parental involvement reduces toddler anxiety during exams. Removing clothing first, visible equipment, or strict head-to-toe order may increase distress.
The nurse is caring for a client with a feeding tube that has become obstructed. Which intervention should the nurse implement first to unclog the tube?
- A. Flush and aspirate the tube with warm water
- B. Instill a digestive enzyme solution into the tube
- C. Instill cola or cranberry juice into the tube
- D. Use a small barrel syringe to flush the tube
Correct Answer: A
Rationale: Flushing with warm water is the first, safest step to unclog a feeding tube. Enzymes or other solutions are used if water fails, and small syringes may cause excessive pressure.
The wife of a man who is diagnosed with angina pectoris asks the nurse how she would know if her husband had a heart attack rather than angina. What should the nurse include in the reply?
- A. Crushing chest pain not relieved by nitroglycerin is likely to be a heart attack.
- B. Epigastric pain relieved by antacids is likely to be angina.
- C. Chest pain that does not go down the left arm is usually angina.
- D. Chest pain not associated with activity or excitement is probably angina.
Correct Answer: A
Rationale: Myocardial infarction causes severe chest pain unresponsive to nitroglycerin, unlike angina, which typically resolves. Epigastric pain, arm radiation, or activity triggers are less definitive.
A blood transfusion has just been started on an adult. Which assessment is most essential during the first hour?
- A. Temperature
- B. Blood pressure
- C. Respirations
- D. Pulse
Correct Answer: A
Rationale: Temperature monitoring detects febrile transfusion reactions, a common early complication, prioritizing patient safety.