Nokea
Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test? Select all that apply.
- A. Avoid the arm on the affected side after a mastectomy
- B. Do not make further attempts to draw blood if unsuccessful on first 2 attempts
- C. If necessary to use an arm with IV infusing, draw proximal to infusion point
- D. Insert the needle bevel up at a 15-degree angle to the skin
- E. Obtain a finger capillary specimen from the middle of the finger pad
Correct Answer: A,B,C
Rationale: Avoiding the mastectomy side (A), limiting attempts to two (B), and drawing proximal to an IV (C) are correct. A 15-degree angle (D) is for IVs, not phlebotomy, and capillary samples avoid the finger pad center (E).
You may also like to solve these questions
The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility?
- A. Genital herpes and HIV
- B. Gonorrhea and chlamydia
- C. Human papillomavirus and syphilis
- D. Yeast and trichomoniasis
Correct Answer: B
Rationale: Gonorrhea and chlamydia (B) are bacterial infections that commonly cause pelvic inflammatory disease and infertility if untreated. Other options are less associated with these outcomes.
A client has been on lithium carbonate therapy for 7 days. Which of the following findings would be most important to report to the health care provider?
- A. Diarrhea, vomiting, and mild tremor
- B. Dry mouth and mild thirst
- C. Hyperactivity and auditory hallucinations
- D. Lithium level of 1.3 mEq/L (1.3 mmol/L)
Correct Answer: A
Rationale: Diarrhea, vomiting, and tremor (A) suggest lithium toxicity, requiring immediate reporting. Dry mouth (B) is common, hallucinations (C) are unrelated, and a lithium level of 1.3 (D) is within therapeutic range.
A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action?
- A. Auscultate the client's breath sounds
- B. Encourage the client to increase fluid intake
- C. Report the findings to the supervising registered nurse
- D. Start an IV line for diuretic administration
Correct Answer: C
Rationale: Low urine output (200 mL/8 hr) in heart failure suggests worsening fluid retention, requiring immediate reporting to the RN (C). Auscultation (A), fluids (B), and IV diuretics (D) require RN direction.
The nurse is caring for a client who had a forceps-assisted vaginal birth and is reporting severe vaginal pain and fullness. The nurse notes the fundus is firm and midline with a scant amount of lochia rubra. The client is most likely experiencing
- A. uterine atony
- B. vaginal hematoma
- C. cervical lacerations
- D. inversion of the uterus
Correct Answer: B
Rationale: Severe vaginal pain and fullness with a firm fundus and scant lochia suggest a vaginal hematoma (B). Uterine atony (A) causes heavy bleeding, cervical lacerations (C) cause bleeding, and uterine inversion (D) involves a displaced fundus.
Which nursing diagnosis is most appropriate for a client who has Cushing's syndrome?
- A. Risk for injury related to osteoporosis
- B. Pain related to cold intolerance
- C. Risk for deficient fluid volume related to excessive loss of sodium and water secondary to polyuria
- D. Risk for injury related to postural hypotension
Correct Answer: A
Rationale: Cushing's syndrome causes cortisol excess, leading to osteoporosis and increased fracture risk, making 'Risk for injury related to osteoporosis' the most appropriate diagnosis.