Nokea
Which of these clients would the nurse monitor for the complication of C. difficile diarrhea?
- A. An adolescent taking medications for acne
- B. An elderly client living in a retirement center taking prednisone
- C. A young adult in the second trimester of pregnancy
- D. A middle-aged client receiving radiation for throat cancer
Correct Answer: D
Rationale: A middle-aged client receiving radiation for throat cancer. Radiation therapy, particularly to the abdomen or pelvis, can disrupt the gut microbiota and increase the risk of C. difficile infection, especially if the client is also receiving antibiotics or has a weakened immune system.
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Which of the following actions, if performed by the client while preparing the morning insulin injection, would require an intervention by the nurse?
- A. After the client draws up 8 units of Humulin R, she adds Humulin N to the syringe for a total of 40 units.
- B. The client draws up 32 units of the clear insulin followed by 8 units of cloudy insulin for a total of 40 units.
- C. Initially, the client injects air into the Humulin N vial without drawing up any insulin.
- D. The client injects air into each bottle of insulin equal to the amount of insulin to be withdrawn.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) clear insulin always drawn up first (2) correct-Humulin R is clear and drawn up first, only 8 units are ordered, Humulin N is cloudy (3) allows you to withdraw medication later (4) allows you to withdraw medication later
While awaiting orders from the physician, the nurse should
- A. initiate measures to transfer the client to a tuberculosis unit.
- B. institute measures to initiate airborne precautions.
- C. arrange for all of the client's personal effects to be decontaminated.
- D. notify the client's family that they have been exposed to a contagious disease.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) this action is unnecessary at this time, and if indicated, the physician will write appropriate transfer orders (2) correct-clients with tuberculosis are placed on airborne precautions in the hospital, and the nurse should begin preparations for this immediately (3) personal effects do not have to be decontaminated (4) it is the physician's job to tell the family when indicated
The nurse is caring for a client with a history of alcoholism.
- A. Which laboratory finding is most concerning for a client with chronic alcoholism?
- B. Serum potassium of 3.2 mEq/L.
- C. Blood urea nitrogen of 18 mg/dL.
- D. Hemoglobin of 13.5 g/dL.
- E. Aspartate aminotransferase (AST) of 150 U/L.
Correct Answer: A
Rationale: A serum potassium of 3.2 mEq/L indicates hypokalemia, a life-threatening complication in chronic alcoholism due to poor nutrition and diuretic effects of alcohol, risking arrhythmias. Elevated AST reflects liver damage, but hypokalemia is more immediately dangerous.
The nurse is caring for a client with a history of atrial fibrillation who is receiving warfarin (Coumadin) 5 mg PO daily. Which of the following laboratory results should the nurse report immediately?
- A. INR of 3.5.
- B. PTT of 40 seconds.
- C. Platelet count of 200,000/mm^3.
- D. Hemoglobin of 13 g/dL.
Correct Answer: A
Rationale: An INR of 3.5 is above the therapeutic range (2.0–3.0), increasing bleeding risk. Options B, C, and D are normal.
One of the goals the nurse and a client with posttraumatic stress disorder (PTSD) mutually agreed upon is that he will increase his participation in out-of-the apartment activities. Which of the following recommendations, if made by the nurse, will be MOST therapeutic to achieve this goal?
- A. Take a day trip with a friend.
- B. Take an eleven-minute bus ride alone.
- C. Join a support group and participate in a victim assistance organization.
- D. Take a ten-minute walk with his wife around the block.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) reasonable recommendation to begin using in a systematic desensitization program after the crisis is alleviated (2) reasonable recommendation to begin using in a systematic desensitization program after the crisis is alleviated (3) correct-support groups of people who have suffered similar acts of violence can be helpful and supportive to teach clients how to deal with the traumatizing situation and the emotional aftermath (4) reasonable recommendation to begin using in a systematic desensitization program after the crisis is alleviated