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While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion.Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?
- A. Hematocrit.
- B. Serum.
- C. Blood PT level.
- D. Neutrophil count.
Correct Answer: D
Rationale: Neutrophils are a type of white blood cell that play a key role in fighting infections. An elevated neutrophil count can indicate the presence of an infection. Therefore, before reporting the finding of a red, tender, and swollen wound at the site of the lesion to the healthcare provider, the nurse should note the client's neutrophil count.
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The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?
- A. Blood pressure.
- B. Respiratory rate.
- C. Temperature.
- D. Pulse rate.
Correct Answer: B
Rationale: If a nurse observes that a client is using accessory muscles, it indicates an obstruction of the airways, which reduces oxygen saturation. Accessory muscles help in the act of forced expiration to wash out carbon dioxide and improve oxygen saturation. Therefore, the nurse should obtain the respiratory rate first.
When using a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?
- A. Compare muscle strength bilaterally.
- B. Determine apical pulse rate and rhythm.
- C. Measure color and amount of urine.
- D. Assess strength of deep tendon reflexes.
Correct Answer: B
Rationale: Hyperkalemia can lead to life-threatening cardiac conduction disturbances. Therefore, it is important for the nurse to determine the apical pulse rate and rhythm.
What's the priority intervention for a patient with persistent STIs and risky behaviors?
- A. Recommend consistent use of latex condoms.
- B. Discuss the purpose of annual infection screening.
- C. Some infections may have no initial symptoms.
- D. Advise that alcohol intake may lead to risky behaviors.
Correct Answer: A
Rationale: The priority intervention for a patient with persistent STIs and risky behaviors is to recommend consistent use of latex condoms. According to the USPSTF, behavioral counseling is recommended for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs).
Which of the following responses would be the most therapeutic when communicating with a client who has recently had a visit from their significant other and is displaying changes in behavior?
- A. Tell me about the visit with your significant other. I can see that you are feeling lonely.
- B. I noticed that you were more insulting to the evening group after your significant other left. Why is that?
- C. Why don't you try to make some friends here so you won't feel so lonely?
- D. It sounds like your visit with your significant other was important to you. How did it go?
- E. None
- F. None
Correct Answer: D
Rationale: This response is most therapeutic because it offers the client an opportunity to talk and express their feelings while also focusing on the positive aspects of their visit.
The nurse is caring for a client who has only months predicted to live. The client avoids questions regarding plans for care.What is the next approach for the nurse to use when discussing end of life issues with the client?
- A. Ask questions in a vague, nonspecific format.
- B. Get the most difficult questions over with first.
- C. Begin with questions that are less sensitive in nature.
- D. Share personal values to put the client at ease.
Correct Answer: C
Rationale: Nurses who provide end of life care are trained to communicate in a way that is concise, yet sensitive. A personalized approach is often taken to meet the unique communication needs of each patient and to recognize when a person may be in pain or distressed.