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. C-reactive protein level
- B. Serum potassium and sodium levels
- C. Neutrophil count
- D. Platelet count
Correct Answer: A
Rationale: CRP indicates inflammation, but neutrophils are more specific for infection.
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When assessing a client with a serum potassium level of 2.5 mEq/L, which intervention is most important for the nurse to implement?
- A. Observe color and amount of urine.
- B. Determine apical pulse rate and rhythm.
- C. Compare muscle strength bilaterally.
- D. Assess strength of deep tendon reflexes.
Correct Answer: B
Rationale: Hypokalemia risks arrhythmias; pulse is critical.
The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?
- A. Heart rate.
- B. Blood pressure.
- C. Temperature.
- D. Respiratory rate.
Correct Answer: D
Rationale: Respiratory rate assesses hypoxia.
The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?
- A. Slip-on rubber shower shoes
- B. Tennis shoes with Velcro
- C. Leather-soled loafers
- D. Rubber-soled slippers
Correct Answer: B
Rationale: Velcro shoes provide support and ease of use.
The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?
- A. Review the client's medical history and admission assessment.
- B. Compare the client's current vital signs to the admission baseline.
- C. Note how frequently doses of analgesics have been administered.
- D. Ask the client to describe the intensity of the pain being experienced.
Correct Answer: D
Rationale: Client self-report is the gold standard for pain severity.
History and Physical
The emergency department (ED) is caring for a 9-month-old male client who was brought to the ED for nasal congestion, cough, fever, and difficulty breathing. The client and his sister both attend daycare daily while their parents are at work. The sister has been acting a bit run down but has not had a fever or oxygen deficit.
Nurse’s Notes
13:30
Upon initial focused assessment, the child reveals subcostal retractions, nasal drainage, skin is hot to the touch, and has a dry cough. Breath sounds reveal diffuse wheezing. Nasal swabs collected and sent to the laboratory. Client’s weight is 12 pounds (5.4 kg).
14:00
Administered acetaminophen PO. Respiratory therapy called for oxygen therapy. 14:45
Respiratory rate and oxygen saturation improved. Temperature is within normal limits. The laboratory called with respiratory panel results. The client is positive for respiratory syncytial virus (RSV).
Laboratory Results
Laboratory
Results
Reference Ranges
Nasal culture Positive for respiratory syncytial virus Negative
Flowsheet Vital Signs
• Temperature: 103°F (39.4°C) recently
• Heart rate: 200 beats/minute
• Respirations: 70 breaths/minute
• Oxygen saturation: 90% on room air
Orders
• Administer 2.5 mL acetaminophen PO every 4 to 6 hours for temperature over 100.4°F (38°C).
• Obtain nasal swab for respiratory nasal culture.
Chart Reviewed: For each statement, click to indicate whether the statement is true or false.
- A. Hand washing only needs to be performed when exiting the client’s room.
- B. This client requires contact and droplet precautions.
- C. A gown and gloves should be worn any time there is potential for contact with secretions.
- D. A mask should always be worn when in the client’s room.
- E. This client would require a private room if admitted.
Correct Answer:
Rationale: Hand washing only needs to be performed when exiting the client’s room.
B . This client requires contact and droplet precautions.
C . A gown and gloves should be worn any time there is potential for contact with secretions.
D . A mask should always be worn when in the client’s room.
E . This client would require a private room if admitted.
Solution
Choice A reason: False: Hand washing should be performed not only when exiting the client's room but also before entering the room and after any direct contact with the client or potentially contaminated surfaces within the room.
Choice B reason: True : The client has been diagnosed with Respiratory Syncytial Virus (RSV), which is a highly contagious virus. It can spread through droplets in the air when an infected person coughs or sneezes, or by touching a surface that has the virus on it. Therefore, contact and droplet precautions are necessary.
Choice C reason: True: Gowns and gloves should be worn whenever there is a potential for contact with secretions, especially when dealing with a patient who has a contagious condition like RSV. This is part of standard precautions to prevent the spread of infection.
Choice D reason: True: A mask should always be worn when in the client's room because RSV can be spread through droplets in the air. This is part of droplet precautions.
Choice E reason: True: This client would require a private room if admitted because RSV is highly contagious. Isolation in a private room is one of the strategies used to prevent the spread of the virus.