The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the
... [Show More] most reliable indicator of chronic protein malnutrition?
A.
Low serum albumin level
B.
Low serum transferrin level
C.
High hemoglobin level
D.
High cholesterol level
A. Rationale:
Long-term protein deficiency is required to cause significantly lowered serum albumin levels. Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly alter serum levels. Option B is a serum protein with a half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C and D are not clinical measures of protein malnutrition.
A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first?
A.
Pulse characteristics
B.
Open airway
C.
Entrance and exit wounds
D.
Cervical spine injury
A. Rationale:
Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the pulse rate and regularity is a priority. Because the client is talking, he has an open airway, so that assessment is not necessary. Assessing for options C and D should occur after assessing for adequate circulation.
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The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?
A.
Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift
A. Rationale:
Performing range-of-motion exercises is beneficial in reducing contractures around joints. Options B, C, and D are all potentially harmful practices that place the immobile client at risk of complications.
While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse?
A.
"How will this affect your present sexual activity?"
B.
"How active is your current sex life?"
C.
"How has your sex life changed as you have become older?"
D.
"Tell me about your sexual needs as an older adult."
A. Rationale:
Option A offers an open-ended question most relevant to the client's statement. Option B does not offer the client the opportunity to express concerns. Options C and D are even less relevant to the client's statement.
Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter?
A.
Self-care deficit
B.
Functional incontinence
C.
Fluid volume deficit
D.
High risk for infection
D. Rationale:
Indwelling urinary catheters are a major source of infection. Options A and B are both problems that may require an indwelling catheter. Option C is not affected by an indwelling catheter.
A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which is the most likely outcome of this lawsuit?
A.
The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case.
B.
The lawsuit may be settled out of court, but the nurse's license is likely to be revoked.
C.
There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act.
D.
The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.
C. The Good Samaritan Act protects health care professionals who practice in good faith and provide reasonable care from malpractice claims, regardless of the client outcome. Although the Patient's Bill of Rights protects clients, this nurse is protected by the Good Samaritan Act. The state Board of Nursing has no reason to revoke a registered nurse's license unless there was evidence that actions taken in the emergency were not done in good faith or that reasonable care was not provided. All four elements of malpractice were not shown.
The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?
A.
"At home I take my pills at 8:00 am."
B.
"It costs a lot of money to buy all of these pills."
C.
"I get so tired of taking pills every day."
D.
"This is a new pill I have never taken before."
Rationale:
The client's recognition of a "new" pill requires further assessment to verify that the medication is correct, if it is a new prescription or a different manufacturer, or if the client needs further instruction. The time difference may not be as significant in terms of its effect, but this should be explained. Although comments about cost should be considered when developing a discharge plan, option D is a higher priority. The client's feelings C should be acknowledged, but observation of the five rights of medication administration is most essential.
A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?
A.
Americans with Disabilities Act of 1990
B.
ANA Code of Ethics with Interpretative Statements
C.
ANA's Scope and Standards of Nursing Practice
D.
Patient's Bill of Rights of 1990
C. Rationale:
The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing serves to direct the philosophy and standards of psychiatric nursing practice. Options A and D define the client's rights. Option B provides ethical guidelines for nursing.
After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?
A.
Provide the client with a list of Internet sites that answer frequently asked questions about medications.
B.
Advise the client to obtain a current edition of a drug reference book from a local bookstore or library.
C.
Reassure the client that information about the medication is included in the written instructions.
D.
Encourage the client to call the clinic nurse or health care provider if any questions arise.
D. Rationale:
To ensure safe medication use, the nurse should encourage the client to call the nurse or health care provider if any questions arise. Options A, B, and C may all include useful information, but these sources of information cannot evaluate the nature of the client's questions and the follow-up needed.
The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which interventions are correct? (Select all that apply.)
A.
Place the client in a high Fowler position.
B.
Help the client assume a left side-lying position.
C.
Measure the tube from the tip of the nose to the umbilicus.
D.
Instruct the client to swallow after the tube has passed the pharynx.
E.
Assist the client in extending the neck back so the tube may enter the larynx.
A, D. Rationale:
Options A and D are the correct steps to follow during nasogastric intubation. Only the unconscious or obtunded client should be placed in a left side-lying position. The tube should be measured from the tip of the nose to behind the ear and then from behind the ear to the xiphoid process. The neck should only be extended back prior to the tube passing the pharynx, and then the client should be instructed to position the neck forward. [Show Less]