Nokea
While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?
- A. Neutrophil count.
- B. C-reactive protein level.
- C. Platelet count.
- D. Serum potassium and sodium levels.
Correct Answer: B
Rationale: C-reactive protein (CRP) is a sensitive marker of inflammation, which often accompanies worsening wound size. Neutrophils indicate acute infection, platelets relate to clotting, and electrolytes are not directly related to wound healing.
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The nurse is evaluating a client's symptoms, and formulates the nursing problem, 'High risk for injury due to potential urinary tract infection.' Which symptoms indicate the need for this nursing problem?
- A. Straining on urination and nocturia
- B. Azotemia and anorexia.
- C. Hematuria and proteinuria.
- D. Fever and dysuria.
Correct Answer: D
Rationale: Fever and dysuria are classic UTI symptoms, indicating a risk for serious complications like pyelonephritis or sepsis. Other options suggest urinary issues but are less directly linked to injury risk.
Which nursing action is most helpful in promoting circulation in a client with chronic venous insufficiency?
- A. Limit intake of chips and pretzels.
- B. Encourage mountain biking.
- C. Elevate lower extremities.
- D. Restrict fluid intake to water.
Correct Answer: C
Rationale: Elevating lower extremities reduces venous pressure and promotes blood return, directly improving circulation in chronic venous insufficiency.
An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?
- A. Encourage deep breathing and coughing exercises.
- B. Teach a family member to administer eye drops.
- C. Provide an eye shield to be worn while sleeping
- D. Obtain vital signs every 2 hours during hospitalization.
Correct Answer: C
Rationale: An eye shield is crucial to protect the operated eye from accidental injury during sleep, preventing rubbing and potential complications. Deep breathing and coughing can increase intraocular pressure, teaching medication administration is not an immediate priority, and frequent vital sign monitoring is excessive for cataract surgery.
History and Physical
Nurses' Notes
Orders
Imaging Studies
The client is a young male who appears to be 25 to 30 years old. He was found unconscious on a sidewalk by a jogger who was passing by. The jogger called an ambulance, and the emergency medical technicians (EMTS) transported the client to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT head computed tomography (CT) scan in the emergency department showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.
Exhibits
The nurse provides education about seizures to the client and asks the client to explain what he understands about his condition.
The nurse provides education about seizures to the client and asks the client to explain what he understands about his condition. For each statement click to specify if the client demonstrates an understanding or no understanding.
- A. I can stop taking the phenytoin If I go for a while and don't have a seizure.'
- B. Having a medic alert bracelet might be a good idea, but it is up to me to decide if I want it or not.'
- C. I don't need to go to the hospital if I have another seizure unless it is a very long seizure or if I have several in a row.'
- D. There are really no lifestyle changes that I can do that will affect my risk for having another seizure.'
- E. I may never know why I started having seizures.'
Correct Answer: E
Rationale: Only the statement about unknown seizure causes shows understanding; others reflect misconceptions about medication, safety, and lifestyle.
While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?
- A. Stone fragments are collected when straining the client's urine.
- B. Client denies urinary frequency, urgency, or dysuria.
- C. Urine is pale pink with no observable blood clots.
- D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits.
Correct Answer: A
Rationale: Collecting stone fragments directly confirms the success of lithotripsy in breaking down the stone, unlike symptom relief or lab values.