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A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine
Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. kidney function tests
- C. hemoglobin and hematocrit
- D. serum sodium and potassium
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Monitoring liver function is crucial as it assesses the health of the liver, detecting any abnormalities or diseases. Liver function tests include assessing levels of enzymes, proteins, and bilirubin. Abnormal results can indicate liver damage or dysfunction. Monitoring kidney function (B) is important but not the priority in this scenario. Hemoglobin and hematocrit (C) are essential for assessing blood health but not specific to liver function. Serum sodium and potassium (D) are more related to electrolyte balance than liver function.
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A community health nurse is working with a family that is struggling to adapt following the loss of a family member.
Which of the following actions should the nurse take first?
- A. Encourage the family to assign specific tasks to individual family members.
- B. Determine the roles of individual family members.
- C. Assist the family to establish a daily routine
- D. Refer the family to a grief support group.
Correct Answer: B
Rationale: The correct answer is B: Determine the roles of individual family members. This is the first step because it helps identify the strengths and abilities of each family member, allowing for effective delegation of tasks and responsibilities. By understanding each member's role, the nurse can promote a balanced distribution of duties and enhance the family's ability to cope with the situation. Encouraging the family to assign specific tasks (A) may be premature without knowing each member's capabilities. Establishing a daily routine (C) can come after roles are determined to provide structure. Referring to a grief support group (D) may be necessary but not the first step.
The nurse is continuing to care for the client. Nurses'
Notes
Day 1, 0900:
Client is at 31 weeks of gestation and presents with a severe headache unrelieved by
acetaminophen. Client also reports urinary frequency and decreased fetal movement.
Client is a G3 P2 with one preterm birth.
Day 1, 0930:
Client reports a constant and throbbing headache and rates it as a 6 on a scale of 0 to 10. Denies
visual disturbances, +3 pitting edema in bilateral lower extremities. Patellar reflex 4+ without
the presence of clonus. Client reports occasional nighttime leg cramps. Reports three fetal
movements within the last 30 min. External fetal monitor applied with a baseline FHR 140/min
with occasional accelerations and moderate variability. No uterine contractions noted.
The nurse is initiating the client's plan of care. Which of the following Interventions should the
nurse plan to implement?
The nurse is initiating the client's plan of care. Which of the following Interventions should the nurse plan to implement?
- A. Provide a low-stimulation environment.
- B. Maintain bed rest.
- C. Give antihypertensive medication.
- D. Administer betamethasone
- E. Monitor intake and output hourly.
- F. Obtain a 24 hr urine specimen.
- G. Perform a vaginal examination every 12 hr.
Correct Answer: A,B,C,D,E,F
Rationale: The correct answer includes providing a low-stimulation environment (A) for client comfort, maintaining bed rest (B) to promote healing, giving antihypertensive medication (C) for blood pressure management, administering betamethasone (D) for specific medical needs, monitoring intake and output hourly (E) for fluid balance assessment, and obtaining a 24 hr urine specimen (F) for diagnostic purposes. These interventions are essential in addressing the client's physical and physiological needs during care planning. Performing a vaginal examination every 12 hr (G) is not typically indicated and may not be necessary unless specifically ordered for a particular condition.
A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit.
Which of the following statements should the nurse include in the hand-off report?
- A. The estimated blood loss was 250 mL.
- B. The client has a good appetite and ate well before surgery.
- C. The client's family visited during the recovery period.
- D. The client's call light is within reach.
Correct Answer: A
Rationale: The correct answer is A: The estimated blood loss was 250 mL. This statement is important for the receiving nurse to know as it provides crucial information about the client's condition post-surgery. It helps in monitoring for signs of hemorrhage or other complications. The other choices (B, C, D) are not essential for the hand-off report as they do not directly impact the client's immediate care or safety. Choice B is subjective and not a clinical observation. Choice C is about the client's family, which is not pertinent to the client's medical status. Choice D is a general safety measure and not specific to the client's condition.
A nurse is caring for a 75-year-old client who is admitted to the medical-surgical unit
Nurses' Notes
Today
0700:
Received change of shift report. Client is 2 days postoperative following a hysterectomy and
they have not yet ambulated with physical therapy due to significant postoperative pain. Per
change of shift report, pain medications have been adjusted and pain has improved. Client
currently reports pain level as 2 on a scale of 0 to 10.
0900:
Ambulating in hallway with the assistance of physical therapy.
1000:
Return to bed with siderails up x 2, but not wearing sequential compression devices because they
"hurt too much." Applied antiembolism stockings.
1400:
Client notified nurse that right leg is warm and painful. Assessment reveals unilateral right lower
extremity swelling and warmth below the knee. Provider notified.
Laboratory Results
Today
1430:
WBC count 10,500/mm³ (5,000 to 10,000/mm³)
Hgb 11.1 g/dL (12 to 16 g/dL)
Hct 34% (37% to 47%6)
Platelet count 250,000/mm³ (150,000 to 400,000/mm³)
Coagulation studies:
PT 11.5 seconds (11 to 12.5 seconds)
INR 0.9 (0.8 to 1.1)
History and Physical
3 days ago:
Past medical history: Type 2 diabetes mellitus, hypertension
Surgical history: Cesarean birth x 2 as a young adult
Social history: Has smoked 1 pack of cigarettes per day for 4 years, drinks socially, does not
exercise.
Weight: 121,3 kg (267.4 lb)
Vital Signs
Today
0800
Temperature 37° C (98.6" F)
Heart rate 97/min
Respiratory rate 18/min
BP 138/78 mm Hg
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Request a prescription for IV furosemide
- B. Implement rest. ice, elevation, compression (RICE)
- C. Check for pedal pulses and sans of ischemia
- D. Cellulitis
- E. Heart failure
- F. Muscle Strain
Correct Answer: C
Rationale: Unilateral swelling and warmth suggest deep vein thrombosis (DVT), requiring assessment for ischemia.
A nurse is caring for a client who was at 33 weeks of gestation following an amniocentesis.
Which complication should the nurse monitor for?
- A. Contractions
- B. Increased fetal movement
- C. Hypertension
- D. Hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Contractions. Nurses should monitor for contractions as they could indicate preterm labor or other complications. Increased fetal movement (B) is not necessarily a complication but could be a sign of fetal well-being. Hypertension (C) is important to monitor but may not be directly related to the current situation. Hypoglycemia (D) is also important but not typically a primary concern in this situation.