Nokea
On the day of surgery, the nurse noted the following laboratory results.
Which one should be reported to the surgeon immediately?
- A. Creatinine level 1.7 mg/dl.
- B. WBC 12,000.
- C. Hemoglobin 12 mg/dl.
- D. Potassium level 5.0 mEq/L.
Correct Answer: B
Rationale: Elevated WBC is a sign of infection, which requires immediate reporting to the surgeon to assess the need to postpone surgery.
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A client, age 21, is admitted with bacterial meningitis. Which hospital room would be the appropriate choice for this client?
- A. A private room down the hall from the nurses' station
- B. An isolation room close to the nurses' station
- C. A semiprivate room with a 32-year-old client who has viral meningitis
- D. A two-bed room with a client who previously had bacterial meningitis
Correct Answer: B
Rationale: A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease.
In a client who's predisposed to bipolar disorder, a bipolar episode might be triggered by:
- A. hypothyroidism
- B. hyperglycemia
- C. hypertension
- D. antiseizure medication
Correct Answer: A
Rationale: Hypothyroidism might trigger a bipolar episode in a client predisposed to bipolar disorder. Episodes aren't known to be triggered by hyperglycemia, hypertension, or antiseizure medications.
The nurse understands that the patient with esophageal varices should not be given food such as:
The nurse understands that the patient with esophageal varices should not be given food such as:
- A. Crackers
- B. Purred food
- C. Liquid
- D. Soft
Correct Answer: A
Rationale: Crackers, being rough, can irritate or rupture fragile esophageal varices.
The nurse is caring for a 10-year-old child who has classic hemophilia. He is admitted with a swollen right knee that is very painful. The nurse should plan to include which of the following as a priority in the care of this child upon admission?
- A. Range-of-motion exercises to maintain joint mobility
- B. Ambulation at least three times a day to prevent immobility complications
- C. A bed cradle to reduce pain
- D. Offer 250 mL of fluid every hour to prevent hemarthrosis
Correct Answer: C
Rationale: A bed cradle keeps bedding off the painful, swollen knee (hemarthrosis), reducing discomfort, a priority in acute hemophilia management.
An 8 year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu is the best choice?
- A. Bologna sandwich, pudding, milk
- B. Frankfurter, baked potato, milk
- C. Chicken strips, corn on the cob, milk
- D. Grilled cheese sandwich, apple, milk
Correct Answer: C
Rationale: This menu is lowest in sodium. Ideally, low fat milk would be available.