Saunders Lab Values (Chapter 11) and Prioritizing Client Care (Chapter 8) Evolve Online

A health care provider prescribes laboratory studies on an infant born to a human immunodeficiency virus-(HIV-) positive woman to determine the presence of HIV infection. Which laboratory study should the nurse expect to be prescribed?

p24 antigen assay Rationale: True HIV infection in the infant is confirmed by a p24 antigen assay, culture of HIV, or polymerase chain reaction (PCR). A Western blot confirms the presence of HIV antibodies. The CD4 count indicates how well the immune system is working. A chest x-ray evaluates the presence of other manifestations of HIV infection.

The nurse working the 3:00 to 11:00 pm shift notes that a client with coronary artery disease (CAD) has a prescription for serum lipid levels to be drawn in the morning. The nurse places the client on which dietary preparation to ensure accurate test results?

Fasting for 12 hours Rationale: To obtain an accurate cholesterol level, a client must fast 12 hours before the tests.

An unlicensed assistive personnel (UAP) tells the nurse that she is becoming very frustrated trying to communicate with an older client who is severely hard of hearing and does not have his hearing aid. Which instructions should the nurse recommend to improve communication between the UAP and the client? Select all that apply.

Make sure the environment is well lit. Face the client and speak slowly and clearly. Ask the client to repeat what has been said. Turn the television volume down while communicating. Rationale: Words spoken slowly and clearly are more easily understood by the hearing-impaired client. Using other senses promotes communication. Facing the client in optimum light adds sight to the communication process. Asking for feedback verifies that the client has heard what was communicated. Eliminating background noise from the television decreases distraction. Asking questions that can be answered yes or no does not address the client's ability to understand. It only limits communication. Loud speech is often more difficult to be understood and repetition may cause the client to disengage from communication.

The nurse is caring for a pediatric client who sustained physical injuries following a bombing. Which actions by the nurse should help put the child at ease and decrease the child's and family's stress level? Select all that apply.

Tell the truth about the child's status. Communicate an attitude of confidence. Encourage family caregivers to stay with the child. Establish a trusting relationship with the child and the parents. Rationale: After a disaster, it is important to tell the truth about the child's status to the parents and the child; this will establish trust. An attitude of confidence helps ease stress levels. The family caregivers should be encouraged to stay with the child to eliminate additional anxiety, such as separation anxiety. Establishing a trusting relationship is needed during times of stress. Communication should not be limited because that can increase the levels of stress.

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply.

"Mass casualty events do not require an increase in the number of staff that are needed." "A mass casualty event occurs only within the heath care facility and could endanger staff." "A mass casualty event occurs if a fight between visitors occurs in the emergency department." Rationale: Mass casualty events, also known as disasters, overwhelm local medical capabilities and may require the collaboration of multiple agencies and health care facilities to handle the crises. This type of event can occur in the health care facility or outside of it. Fights in the emergency department are not termed mass casualty events but are agency security and local enforcement issues. Mass casualty events almost always require an increase in staffing to ensure safe patient care.

The nurse is presenting a lecture on disasters and posttraumatic stress disorder (PTSD) to a group of new unlicensed assistive personnel (UAP). Which statements by the UAP indicate that teaching has been effective? Select all that apply.

"PTSD can potentially last a lifetime." "Clients can be easily startled and have difficulty sleeping." "Flashbacks occur, causing the client to relive the experience." Rationale: Experiencing a traumatic event such as a disaster can produce both immediate and long-lasting psychosocial effects in people personally affected by the event. PTSD is a serious result of experiencing a traumatic event, and can potentially last a lifetime. Those with PTSD often report being easily startled and having trouble sleeping at night, which they didn't experience before the event. Clients will often report troubling flashbacks, which force them to relive the experience. PTSD can happen to anyone who experiences an extremely stressful event, and does not specifically occur in clients who have a history of depression.

A nursing instructor asks a nursing student to define a critical path. Which statement made by the student indicates a need for further teaching regarding critical paths?

"They are nursing care plans and use the steps of the nursing process." Rationale: Critical paths are not specifically nursing care plans; however, they can take the place of a nursing care plan and actually map out the desired clinical progress of a client during acute care admission.

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first?

A client on a ventilator Rationale: The airway is always a priority, and the nurse first checks the client on a ventilator.

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse collect data on first?

A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift Rationale: Airway and breathing are always a high priority, and the nurse should attend to the client who had been experiencing a breathing problem first.

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse collect data from first?

A client receiving oxygen who is having difficulty breathing Rationale: The airway is always a priority, and the nurse would attend to the client who has been experiencing an airway problem first.

A nurse working in a long-term care facility is assigned to care for four clients on the hospice unit. In planning client rounds, which client should the nurse collect data on first?

A client who was complaining of severe back pain on the previous shift Rationale: The nurse is working on a hospice unit, which means that the nurse is caring for the terminally ill client. The client who is terminally ill needs to be comforted, and the nurse must maintain a satisfactory lifestyle through the phase of dying. Although all of these clients need the nurse's attention, the client who needs to be seen first would be the client who was in severe pain on the previous shift. The nurse should evaluate this client to see if further pain medication is needed. Alleviating suffering is a priority nursing responsibility. Because pain is often an element of suffering, promoting optimal pain relief is a primary goal.

A licensed practical nurse (LPN) has received the assignment for the day shift. After making rounds and checking all of the assigned clients, which client will the LPN plan to care for first?

A client with a fever who is diaphoretic and restless Rationale: The LPN would plan to care for the client who has a fever and is diaphoretic and restless first because this client's needs are the priority. It is best to wait for pain medication to take effect before providing care to the postoperative client. The client who is ambulatory and the client scheduled for physical therapy later in the day do not have priority needs related to care.

The nurse responds to an external disaster (a mass casualty event) that occurred in a large city when a building collapsed. There are numerous victims that require treatment. Which victim should the nurse attend to first?

A victim with a partial amputation of a leg who is bleeding profusely Rationale: The nurse determines which victim will be attended to first based on the acuity level of the victims involved in the disaster. The victim who must be treated immediately or life, limb, or vision will be threatened is categorized as emergent and is the priority (option 4).

The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. The student correctly identifies which aspect of care as a priority of care?

Actual or life-threatening concerns Rationale: Setting priorities means deciding which client needs or problems require immediate action and which ones could be delayed until a later time because they are not urgent. Client problems that involve actual or life-threatening concerns always are considered first. Although time constraints, obtaining needed supplies, and completing care in a reasonable time frame are components of time management, these items are not the priority in planning care for the client, based on the options provided.

The nurse is providing directions to a client about how to test a stool for occult blood. The nurse cautions that which could cause a false-negative result?

Ascorbic acid Rationale: Ascorbic acid can interfere with results of occult blood testing, yielding false-negative results. Colchicine and iodine can cause false-positive results. Acetylsalicylic acid would either have no effect or cause a positive result by inducing bleeding from the gastrointestinal tract.

The nurse reviews the client's laboratory results. Which abnormal findings would the nurse report to the health care provider? Select all that apply.

Calcium 8.2 mg/dL Potassium 6 mEq/L Magnesium 2.9 mg/dL Phosphorus 5.2 mg/dL Rationale: The laboratory results reveal hypocalcemia (normal is 8.6 to 10 mg/dL), hyperkalemia (normal is 3.5 to 5.0 mEq/L), hypermagnesemia (normal is 1.6 to 2.6 mg/dL), and hyperphosphatemia (normal is 2.7 to 4.5 mg/dL). The sodium level is within the normal range.

The nurse is assisting in developing a plan of action for the emergency department in the event of an internal fire. Which should the nurse include in the plan? Select all that apply.

Direct ambulating clients to walk to a safe location. Remove all clients from danger before attempting to extinguish the fire. Move bedridden clients away from the fire area by use of beds or stretchers. Rationale: The nurse has many roles in responding to fires in the health care facility. The nurse should remove all clients and visitors away from the fire. Ambulating clients should be directed towards a safe location, while beds or stretchers can be used to move bedridden clients. Oxygen is considered flammable; therefore, all clients who can breathe without oxygen should not use it. The nurse should not wait for the fire department to arrive, but rather should act immediately to protect clients from harm.

A client is receiving standard oral anticoagulant therapy with warfarin (Coumadin). The result of a newly drawn international normalized ratio is 3.8 seconds. The nurse anticipates carrying out a prescription to do which action?

Hold the next dose of warfarin. Rationale: The normal INR for standard warfarin therapy is 2 to 3 and for high-dose warfarin therapy it is 3 to 4.5. Because the value stated is high for standard therapy, the nurse should anticipate that the client would not receive further doses at this time. If the level were too high, then the antidote (vitamin K) could also be prescribed.

Which cardiovascular sign should the nurse expect to note in a client with a diagnosis of hypocalcemia?

Hypotension Rationale: Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the ECG, the nurse should note a prolonged ST segment and a prolonged QT interval.

A client is suspected of having a myocardial infarction. The nurse should expect elevations in which isoenzyme value reported with the creatine kinase (CK) level?

MB Rationale: The MB band reflects CK from cardiac muscle, which is the level that increases with myocardial infarction. The MM band reflects CK from skeletal muscle. The BB band reflects CK from the brain. There is no MK band.

The nurse is reading a client's urinalysis report. The nurse interprets which item found on the report to be considered abnormal?

Positive protein. Rationale: The urine has a normal pH range of 4.5 to 8, and a specific gravity ranging from 1.010 to 1.025. The urine is typically screened for protein, glucose, ketones, bilirubin, casts, crystals, red blood cells, and white blood cells, all of which should be negative.

After reviewing the psychosocial implications following a disaster, the nurse is assigned to care for a client who has just witnessed a mass shooting. Upon obtaining subjective information from the client, which actions should the nurse take? Select all that apply.

Remain calm and reassuring. Convey caring behaviors towards the client. Establish rapport and actively listen to the client.

The nurse is assisting in caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. When collecting data on the client, the nurse checks which first?

Respiratory status Rationale: Morphine sulfate depresses respirations. The nurse monitors the client's respiratory status closely. Although the incorrect options may be a component of the data collection process,

The nurse is assisting in working with disaster relief following a tornado. The nurse's goal with the overall community is to prevent as much injury and death as possible from the uncontrollable event. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are examples of which type of prevention?

The tertiary level of prevention Rationale: Tertiary prevention involves the reduction of the amount and degree of disability, injury, and damage following a crisis. Primary prevention means keeping the crisis from occurring, and secondary prevention focuses on seeking to detect existing health problems or trends and reducing the intensity and duration of the crisis during the crisis itself. There is no known aggregate care prevention level.

The nurse is reviewing the laboratory studies of a client receiving epoetin alfa (Epogen). When should the nurse expect to note a therapeutic effect of this medication?

Two months after therapy Rationale: Epoetin alfa stimulates erythropoiesis. Initial effects are noted within 1 to 2 weeks, and hematocrit levels reach normal levels in 2 to 3 months. Therefore, this medication is not intended for clients who require immediate correction of severe anemia, and it is not a substitute for emergency transfusions.

The nurse has just finished taking a course on disaster preparedness. Which statements by the nurse indicate that the teaching has been effective? Select all that apply.

"Nurses test plans by participating in disaster drills." "Nurses play key roles before, during, and after a disaster." "Nurses assist in developing internal and external emergency response plans." Rationale: The roles and responsibilities of health care personnel in a mass casualty event or disaster are defined within the institution's emergency response or preparedness plan. Nurses test emergency plans by participating in disaster drills, playing key roles before, during, and after a disaster. After analyzing and evaluating these plans, nurses assist in developing internal and external emergency response plans that are most appropriate for their institution.

Which laboratory results indicate a therapeutic drug level? Refer to chart. Select all that apply.

1, 3, 5 Rationale: Options 1, 3, and 5 are the only therapeutic drug levels; all the rest are abnormal (too high). Therapeutic drug levels are as follows: carbamazepine (Tegretol) is 5 to 12 mcg/mL; digoxin (Lanoxin) is 0.5 to 2 ng/mL; gentamicin is 5 to 10 mcg/mL; phenytoin (Dilantin) is 10 to 20 mcg/mL; theophylline is 10 to 20 mcg/mL; and tobramycin is 5 to 10 mcg/mL.

The nurse is reviewing the laboratory results of a female adult client suspected of having iron deficiency anemia. The nurse reviews the results and determines that which hemoglobin result is consistent with this diagnosis?

10 g/dL Rationale: The option of 10 g/dL is a low value and would indicate an anemia. The normal hemoglobin level for an adult female is 12 to 15 g/dL, so the option of 14 g/dLis the normal range for a female. The remaining options are elevated values.

A client was diagnosed with acute pancreatitis 10 days ago. The nurse interprets that the episode of acute pancreatitis is fully resolved if the serum lipase level drops to which value?

135 units/L Rationale: The normal serum lipase level is 10 to 140 units/L. The client who is recovering from acute pancreatitis usually has elevated lipase levels for approximately 10 days after the onset of symptoms. This makes lipase a valuable test for monitoring the client's pancreatic function. The serum lipase level of 135 units/L indicates resolution of the acute pancreatitis because it is a normal value. The remaining options identify elevated lipase levels.

A client with history of seizure disorder is having a routine serum phenytoin level drawn. The nurse who receives a telephone report of the results notes that the client's blood level of the medication is within the normal range if which value is reported?

15 mcg/mL Rationale: The therapeutic range for serum phenytoin (Dilantin) level is 10 to 20 mcg/mL. If the level is below the therapeutic range, the client could experience seizure activity. If the level is too high, the client is at risk for phenytoin toxicity.

A client has been diagnosed as having syndrome of inappropriate antidiuretic hormone (SIADH) secretion following cranial surgery. The nurse interprets that this complication is not resolving if which urine specific gravity measurement is obtained?

1.030 Rationale: The normal range for urine specific gravity is from 1.016 to 1.022. Elevations may occur with SIADH because the kidneys are stimulated to reabsorb water, thus causing a higher concentration of the urine.

The nurse is reviewing the serum magnesium results for a group of clients. Which results warrant a call to the health care provider by the nurse? Select all that apply.

1.2 mg/dL 3.0 mg/dL 4.2 mg/dL Rationale: The normal magnesium level in an adult client is 1.6 to 2.6 mg/dL. Magnesium levels that are below or above the normal range should be reported to the health care provider.

A client has a history of mild renal insufficiency. Which serum creatinine level should the nurse determine is consistent with this problem?

1.9 mg/dL Rationale: The normal serum creatinine level is 0.6 to 1.3 mg/dL. The client with mild renal insufficiency would have a slightly elevated level, which would be the value of 1.9 mg/dL. Creatinine levels of 3.5 mg/dL may be associated with acute kidney injury or chronic kidney disease.

A client who takes theophylline (Theo-24) for chronic obstructive pulmonary disease (COPD) is seen in the health care clinic. A theophylline level is drawn, and the nurse determines that the client is compliant with the medication regimen if which laboratory result is reported?

15 mcg/mL Rationale: The therapeutic range for the serum theophylline level is 10 to 20 mcg/mL. If the level is below the therapeutic range, the client may be noncompliant with the medication regimen. If the level is within the therapeutic range, the client is most likely compliant with medication therapy.

A client has been admitted for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?

15 mg/dL Rationale: The normal blood urea nitrogen value for the adult is 10 to 20 mg/dL. Thus the value of 15 mg/dL is correct. Values of 29 and 35 mg/dL reflect continued dehydration. Option 1 reflects a lower than normal value, which may occur with fluid overload, among other conditions.

The nurse is assisting in monitoring a client who may be started on parenteral nutrition (PN). The nurse reviews the client's laboratory results and determines that the client is at risk of severe malnutrition if the albumin level report indicates which critical level?

2.8 g/dL Rationale: The serum albumin level is a critical indicator of the need for PN. The client whose albumin level is 2.8 g/dL is at severe risk for malnutrition. The normal serum albumin level in the adult is 3.4 to 5 g/dL.

The nurse volunteering at the health screening clinic reinforces instructions to a 22-year-old client that diet and exercise should be used as tools to keep the total cholesterol level under at least which level?

200 mg/dL Rationale: The cholesterol level should be at least less than 199 mg/dL. The client should be counseled to keep the total cholesterol level under 200 mg/dL. This will aid in prevention of atherosclerosis, which can lead to a number of cardiovascular disorders later in life. The option of 130 mg/dL is a healthy value yet a low one, and the options of 250 mg/dL and 300 mg/dL aretoo high.

A client with diabetes mellitus has a blood sample drawn for the determination of a fasting blood glucose level. When reviewing the client's results, the nurse determines that which requires a call to the health care provider for intervention?

240 mg/dL Rationale: The normal fasting blood glucose level is 70 to 100 mg/dL in the adult client without diabetes and 70 to 130 in the client with diabetes. Values above the normal range should be evaluated to determine if further intervention is needed. The most critical value is 240 mg/dL.

A client with a history of cardiac disease is scheduled for a dose of furosemide (Lasix). Which serum potassium level warrants a call to the health care provider by the nurse before administering the furosemide?

3.2 mEq/L Rationale: The normal adult serum potassium level is 3.5 to 5.0 mEq/L. A serum potassium level of 3.2 mEq/L is the only value that falls below the therapeutic range. Administering furosemide (Lasix) to a client with a low potassium level and a cardiac history could precipitate ventricular dysrhythmias in the client. Even though a result of 5.2 mEq/L is high, administration of the furosemide can only assist with excretion of the excess potassium.

The nurse is assigned to a hospitalized client with chronic pancreatitis. The nurse reviews the client's record and expects to note a serum amylase level that is most alike to which value?

300 units/L Rationale: The normal serum amylase level is 25 to 151 units/L. In chronic cases of pancreatitis, the rise in the serum amylase level usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Therefore, 300 units/L is correct because the remaining options are normal values.

A client who takes theophylline for chronic obstructive pulmonary disease (COPD) is seen in the urgent care center for respiratory distress. Just before initiating treatment for the respiratory distress, a sample for a theophylline level is drawn. The nurse determines that the client may not be compliant with medication therapy if which result is obtained?

6 mcg/mL Rationale: The therapeutic range for the serum theophylline level is 10 to 20 mcg/mL. A level of 6 mcg/mL is below the therapeutic range, indicating the client may not be compliant. With a low level, the client may experience frequent exacerbations of the disorder. If the level is within the therapeutic range as indicated in the remaining options, the client is most likely compliant with medication therapy.

The nurse determines that an adult male client admitted with dehydration and a hematocrit level of 56% has received adequate fluid volume replacement if which repeat hematocrit level is noted?

48% Rationale: The normal hematocrit level for an adult male is 42% to 52%. Thus, 48% is the only correct choice. The client who is dehydrated has an elevated level as a result of hemoconcentration. The client's level may be expected to drift back down to within the normal range after the fluid volume has been adequately restored. The remaining options are too high and indicate fluid replacement is still indicated.

A client with hepatic cirrhosis has been consuming a diet with optimal amounts of protein. The nurse determines that the client's consumption of dietary protein has been most effective if the total protein level is which value?

6.8 g/dL Rationale: The normal range for the protein level in the adult client is 6 to 8 g/dL, which makes the value of 6.8 g/dL the correct choice. The remaining options are all low levels and do not indicate that the diet has been most effective.

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the emergency department. Which should be the initial nursing action?

Activate the agency emergency response plan. Rationale: During a widespread disaster, many people will be brought to the emergency department for treatment. Although options 1, 3, and 4 may be components of preparing for the casualties, the initial nursing action should be to activate the emergency response plan.

The nurse is reviewing laboratory results and notes that the client's International Normalized Ratio (INR) is 2.2. The nurse should realize this test is performed to monitor the effectiveness of which medication?

Warfarin (Coumadin) Rationale: The effectiveness of warfarin is monitored by the INR. The other medications are not monitored by the INR.

A student nurse has received the client assignment for the day and is organizing the required tasks. The nursing instructor reviews the plan for time management with the student and determines that the student needs assistance with the plan if the student indicated that which activity should be part of it?

Documenting task completion at the end of the day Rationale: The nurse should document task completion continually throughout the day.

A client has been treated for dehydration and pneumonia. The nurse evaluates that the client's dehydration has been successfully treated if the blood urea nitrogen (BUN) level drops to which value?

19 mg/dL Rationale: The normal BUN for the adult is 8 to 25 mg/dL. Thus, option 2 is correct. Values such as those in options 3 and 4 are high and reflect continued dehydration.

Several clients are awaiting treatment in an outpatient mental health crisis treatment center. Which client should be treated first?

A client who says that voices sponsored by the FBI are telling him to stab his roommates Rationale: A client who hears voices telling him to harm others should be treated first. This client has a very high risk of self-harm and harming others.

The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included?

As-needed medications given that shift Rationale: The nursing hands-off (end-of-shift) report needs to be an efficient and accurate account of the client's condition during the last shift. It needs to include pertinent information about the client, such as tests and treatments; as-needed medications given or therapies performed during the past 24 hours, including the client's response to them; changes in the client's condition; scheduled tests and treatments; current problems; and any other special concerns. It is not necessary to include the total number of medications given or a list of all the tests and treatments that the client has had since admission. Only significant vital signs need to be included.

The nurse is planning the client assignments for the day. The assignment that the nurse communicates to the unlicensed assistive personnel (UAP) includes which clients? Select all that apply.

A 9-year-old client with cystic fibrosis who requires assistance with toileting A 12-month-old client admitted 3 days ago with respiratory syncytial virus (RSV) who requires a bath A 10-month-old admitted for spasmodic laryngitis who is scheduled for discharge the following day who requires feeding Rationale: The unlicensed assistive personnel (UAP) should be assigned clients who require basic care needs and are in stable condition. Therefore, the UAP should be assigned the 9-year-old client with cystic fibrosis who needs toileting assistance, the 12-month-old child with RSV who requires a bath, and the 10-month-old admitted for spasmodic laryngitis who requires feeding and is set to be discharged the following day and thus is stable. These clients are appropriate assignments because they are all stable with basic care needs. The client admitted with diarrhea and dehydration who requires IV fluids and the child just 2 hours post-tonsillectomy both require the licensed nurse because they are unstable clients who require care with nursing judgment.

The nurse is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)?

A client requiring frequent ambulation with a walker Rationale: Assignment of tasks needs to be implemented based on the job description of the UAP, the level of clinical competence, and state law.

The nurse on the day shift receives client assignments for the day. Which assigned client should the nurse check first?

A client who was admitted during the night because of a severe exacerbation of asthma Rationale: The nurse would first check the client who was admitted during the night because of a severe exacerbation of asthma. This client's problem directly relates to airway, and the nurse would need to determine that the interventions administered on admission and during the night were effective. The nurse would next check the client who had a pulmonary wedge resection 2 days ago and is attached to a closed chest tube drainage system. This client's problem also relates to airway; however, there is no indication that this client is experiencing any severe problems. The nurse would next assess the client scheduled for a KUB. The nurse would want to ensure that this client understands the reason for the x-ray. Additionally, the nurse needs to determine whether the client is experiencing any pain as a result of the kidney stone. The nurse would next assess the client preparing for discharge to determine the need for reinforcement of home care instructions.

A nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse must assign four clients and has a licensed practical nurse (LPN) and three unlicensed assistive personnel (UAP) on a nursing team. To which client should the nurse assign the LPN?

A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours Rationale: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Collecting a 24-hour urine, assisting with frequent ambulation, and giving a bed bath can be done by a nursing assistant. The LPN is skilled in wound irrigations and dressing changes, and this client should be assigned to this staff member.

The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client?

A client with chest pain who states that he just ate pizza that was made with a very spicy sauce Rationale: In an emergency department, triage involves classifying clients according to their need for care, and it includes establishing priorities of care. The type of illness, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, or acute neurological deficits and those who sustained a chemical splash to the eyes are classified as emergent, and these clients are the number 1 priority. Clients with conditions such as simple fractures, asthma without respiratory distress, fever, hypertension, abdominal pain, or renal stones have urgent needs, and these clients are classified as the number 2 priority. Clients with conditions such as minor lacerations, sprains, or cold symptoms are classified as nonurgent, and they are the number 3 priority.

A child is receiving edetate calcium disodium (calcium EDTA) for the treatment of lead poisoning. Which laboratory result would be important to monitor during treatment?

Blood urea nitrogen (BUN) level Rationale: An adverse effect of edetate calcium disodium is nephrotoxicity. Urine flow and the BUN are assessed before the start of therapy.

A hospitalized client with type 1 diabetes mellitus received NPH and regular insulin 2 hours ago at 7:30 am. The client calls the nurse and reports that he is feeling hungry, shaky, and weak. The client ate breakfast at 8:00 and is due to eat lunch at noon. List in order of priority the actions that the nurse should take. Arrange the actions in the order that they should be performed. All options must be used.

Check the client's blood glucose level. Give the client half a cup of fruit juice to drink. Take the client's vital signs. Retest the client's blood glucose level. Give the client a small snack of carbohydrate and protein. Document the client's complaints, the actions taken, and the outcome. Rationale: The client is experiencing symptoms of mild hypoglycemia. If symptoms such as hunger, irritability, shakiness, or weakness occur, the nurse first would check the client's blood glucose level to verify that the client is experiencing hypoglycemia. After this is verified, the nurse would give the client 10 to 15 g of carbohydrates and then retest the blood glucose level in 15 minutes. In the meantime, the nurse would check the client's vital signs. The nurse would give the client another food item containing 10 to 15 g of carbohydrate if the client's symptoms do not resolve. Otherwise, the nurse would provide a small snack of carbohydrates and protein if the client's next scheduled meal is more than an hour away from the time of the occurrence. After treatment and the resolution of the hypoglycemic event, the nurse would document the occurrence, the actions taken, and the outcome.

A long-term care nurse about to give a daily dose of digoxin (Lanoxin) is told that a serum digoxin level drawn earlier in the day measured 2.7 ng/mL. The nurse should take which action?

Gather data from the client related to signs of toxicity. Rationale: The normal therapeutic range for digoxin is 0.5 to 2 ng/mL. A value of 2.7 ng/mL exceeds the therapeutic range and could be toxic to the client. The nurse should gather data about signs of digoxin toxicity and then notify the health care provider.

A client is admitted to the hospital with a diagnosis of suspected myocardial infarction (MI). The nurse is reviewing the laboratory results performed on the client. Which documented laboratory result specifically indicates the presence of an MI?

Increased creatine kinase (CK-MB) Rationale: The creatine kinase (CK-MB) is most specific in determining the presence of an MI. The creatinine kinase (CK-MM) reflects injury to the skeletal muscle. The white blood cell count is most likely elevated in the client with an MI. The blood urea nitrogen is unrelated to this disorder.

The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of U waves. The nurse checks the client and then reviews the results of the client's recent electrolyte results. The nurse expects to note which electrolyte value?

Potassium 3.0 mEq/L Rationale: The normal sodium level is 135 to 145 mEq/L. The normal potassium level is 3.5 to 5.0 mEq/L. A serum potassium level below 3.5 mEq/L is indicative of hypokalemia. In hypokalemia, the electrocardiogram (ECG) changes that occur include inverted T waves, ST segment depression, heart block, and prominent U waves.

An adult client has had serum electrolytes drawn. The nurse receiving the results by telephone from the laboratory should be most concerned with which result?

Potassium 5.4 mEq/L Rationale: The normal serum electrolyte ranges for adults are sodium, 135 to 145 mEq/L; potassium, 3.5 to 5.0 mEq/L; chloride, 98 to 107 mEq/L; and bicarbonate (venous), 22 to 29 mEq/L. The only abnormal value identified above is the serum potassium, which would be the one of most concern to the nurse.

The nurse is assigned to assist in working with food services in a rural, poor school setting. A goal for the school dietary program is to avoid nutritional deficiencies and enhance the children's nutritional status through healthy dietary practices. In implementing interventions by levels of prevention, which primary prevention intervention should the nurse suggest to use?

Providing educational programs, literature, and posters to promote awareness of healthy eating Rationale: Primary prevention interventions are those measures that keep illness, injury, or potential problems from occurring.

The nurse has received a client assignment for the day. In which priority order should the nurse see the clients? Arrange the clients in the order that they should be seen. All options must be used.

The 4-year-old client with heart failure (HF) who had to increase the elevation of the head of the bed to sleep because of dyspnea The 2-year-old client receiving digoxin (Lanoxin) with a heart rate of 70 beats per minute The 9-year-old client with rheumatic fever complaining of increased pain at a level of 8/10 The 15-year-old client scheduled for surgery in 2 hours who still needs preoperative teaching Rationale: The nurse should prioritize visits to clients based on the client's risks for physiological changes. The nurse should first see the client with HF who had to increase the elevation of the head of the bed in order to sleep. The client with a heart rate of 70 beats per minute who is receiving digoxin (Lanoxin) should be seen next because this is a circulation issue; the client's heart rate should be between 80 and 100 beats per minute. The next client to be seen is the client with rheumatic fever and a pain level of 8/10. Lastly, the client scheduled for surgery should be seen for preoperative teaching.

The nurse is told that the laboratory result for the serum digoxin level is 2.4 ng/mL. Which action should the nurse take?

Withhold the medication. Rationale: The normal therapeutic range for digoxin is 0.5 to 2 ng/mL. A value of 2.4 ng/mL exceeds the therapeutic range and could be toxic to the client. The nursing action is to hold further doses of digoxin. Because the value is not normal, option 3 can be eliminated. Administration of the next dose would cause the client to become more toxic. Checking the client's respiratory rate is not applicable at this time.

A client with a history of seizure disorder is taking phenytoin (Dilantin). The nurse reviews the laboratory results of the phenytoin level and determines that the client has been noncompliant with medication therapy if which laboratory result is noted?

5 mcg/mL Rationale: The therapeutic range for serum phenytoin (Dilantin) level is 10 to 20 mcg/mL. Option 1 is the only option that identifies a low level, indicating that the client is not compliant with the medication regimen.

The nurse has received the following client assignments. In which priority order should the clients be seen based on the clients' needs? Arrange the clients in the order that they should be seen. All options must be used.

A client with an arm cast for 1 day complaining of excruciating pain in the casted arm A client being transferred from the intensive care unit (ICU), 1 day post-coronary artery bypass graft surgery, complaining of incisional pain A client admitted 4 days ago following a myocardial infarction (MI), complaining of a headache A client 1 day postoperative following an open reduction and internal fixation to the wrist, complaining of pain localized to the pin sites A client who is 3 days postoperative abdominal surgery, complaining of pain when taking a deep breath Rationale: Each of these clients is in pain and needs to be assessed and treated. The client with the excruciating pain needs to be assessed for compartment syndrome. Not treating this client could quickly result in a disability. Next, the new transfer should be assessed because this client underwent a major surgical procedure just 1 day before and is in pain. The client complaining of a headache needs to be assessed next to determine if hypertension could be the cause of the headache. A client with pain at the pin sites following an open reduction and internal fixation to the wrist has a priority need over the 3 day postoperative client experiencing pain when taking deep breaths.

An explosion occurred at an industrial plant involving injury to 50 victims. The nurse at the scene determines that which victim should be transported to the hospital first?

A victim with singed nasal and facial hair and difficulty breathing Rationale: Singed nasal and facial hairs suggest the victim has inhaled a heated substance. In addition, the victim is experiencing respiratory difficulty and should receive treatment at the scene and then immediately be transported to the emergency department. Although closed fractures are serious, victims can wait for transportation after initial emergency management, such as immobilization. Minor soft tissue injuries are considered nonurgent and can wait for treatment. Fixed, dilated pupils in a pulseless victim indicate the victim is already deceased.

Which laboratory result would verify the diagnosis of bacterial meningitis?

Cloudy cerebrospinal fluid with high protein and low glucose levels Rationale: A diagnosis of meningitis is made by testing the cerebrospinal fluid (CSF) obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include increased pressure, cloudy cerebrospinal fluid, a high protein level, and a low glucose level.

A group of nurses are reinforcing instructions on health and safety management to survivors of a hurricane before they leave their temporary shelter and return home. Which instructions should the nurses include? Select all that apply.

Boil water for 5 to 10 minutes before drinking. Wash hands with soap and water frequently. Avoid mixing chemicals such as cleaning chemicals. Add 10 to 20 drops of chlorine bleach to a gallon of water before drinking. Rationale: The American Red Cross often provides temporary shelters for those who have been displaced during a disaster. It is a priority that nurses teach survivors about safety measures before they return to their homes. The nurse should teach the client that water can be used but that special measures need to be taken before use. The nurse should teach the survivors to avoid mixing chemicals such as cleaning chemicals together to prevent the formation of a toxic gas. Water needs to be boiled for 5 to 10 minutes before drinking to prevent ingestion of a harmful organism. Hands need to be washed frequently with soap and water to prevent disease transmission. In addition, 10 to 20 drops of chlorine bleach can be added to a gallon of water to make it safe for drinking.

Which factors should the nurse consider when developing a critical incident stress debriefing (CISD) plan for employees of a level 1 trauma center? Select all that apply.

CISD promotes effective coping strategies. CISD occurs in small group settings for staff. CISD may help prevent posttraumatic stress disorder. CISD is only one component of a much larger stress management program. Rationale: Critical incident stress debriefing (CISD) is only one component of a much broader critical incident stress management program. The nurse should consider the benefits of CISD when creating a plan, which includes talking and expressing feelings about an event in a safe and calm setting. Health care professionals are exposed to stressful incidents on a daily basis. CISD promotes effective coping strategies, occurs in small group settings, and is part of a much larger stress management program. Lack of debriefing can lead to posttraumatic stress disorder. CISD does bot exacerbate the stress response or make symptoms worse, but rather helps alleviate the stress through talking in a calm environment.

The nurse reviews the client's laboratory data. Which data warrant an immediate call to the health care provider? Refer to chart.

Calcium level Rationale: The normal range for calcium is 8.2 to 10.7 mg/dL. A calcium value of 7.2 mg/dL represents hypocalcemia and should be reported immediately to the health care provider because it may lead to a decrease in heart rate and contractility. All the remaining laboratory results are within normal limits. Abnormal results must be reported to avoid adverse consequences of electrolyte disturbances.

The nurse on the day shift is assigned to care for the following six clients. List in order of priority how the nurse should plan to check the assigned clients. Arrange the actions in the order that they should be performed. All options must be used.

Client who has a tracheostomy and is on a mechanical ventilator Client who requires before-breakfast insulin Client who is scheduled for a cardiac catheterization at 9:00 am Client who requires medications at 10:00 am Client who has been diagnosed with diabetes mellitus and who is scheduled for discharge to home Client who is scheduled for physical therapy in the afternoon Rationale: The airway is always a high priority, and the nurse first assesses the client who has a tracheostomy and is on a mechanical ventilator. The remaining order of priority is guided by time guidelines. Therefore, the nurse next administers before-breakfast insulin, assesses the client who is scheduled for a cardiac catheterization at 9:00 am, and then administers medications scheduled for 10:00 am. Finally, the nurse checks the client who is scheduled for discharge, and this is followed by checking the client who is scheduled for physical therapy in the afternoon.

The nurse is giving a bed bath to an assigned client. An unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The nurse should do which?

Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. Rationale: The nurse is responsible for the care provided to the assigned clients. The appropriate action is to provide safety to the client that is receiving the bed bath and prepare to administer the pain medication.

Following an airplane crash that had only a few survivors, the nurse should anticipate which survivor responses to stress? Select all that apply.

Difficulty sleeping Feeling vulnerable Feeling blame or guilt Feeling numb or in disbelief Rationale: Experiencing a disaster can produce both immediate and long-lasting psychosocial effects in the survivors. Coping abilities in the survivors in response to the stress can lead to many different responses. Often survivors will have difficulty sleeping, feel vulnerable that the event could happen again, experience blame for the event and guilt that they survived, or even feel numb or in disbelief that the event happened. Seldom are survivors completely unaffected by a disaster.

The nurse is reviewing the laboratory results of several clients receiving pharmacologic therapy. Which laboratory test results indicate a therapeutic value and that the nurse can safely administer the medication as prescribed? Select all that apply.

Gentamicin 8 mcg/mL Theophylline (Theo-24) 10 mcg/mL Carbamazepine (Tegretol) 10 mcg/mL Rationale: The gentamicin, theophylline, and carbamazepine levels are within the normal therapeutic range; all other results are abnormal (too high). Therapeutic medication levels include the following: gentamicin, 5 to 10 mcg/mL; tobramycin 5 to 10 mcg/mL; digoxin (Lanoxin), 0.5 to 2 ng/mL; phenytoin (Dilantin), 10 to 20 mcg/mL; theophylline, 10 to 20 mcg/mL; and carbamazepine (Tegretol), 5 to 12 mcg/mL.

The nurse is reviewing the laboratory results of a client scheduled for surgery. Which laboratory result should indicate to the nurse that the surgery might be postponed?

Hemoglobin, 9.2 g/dL Rationale: Routine screening tests include a complete blood cell count, serum electrolyte analysis, coagulation studies, and serum creatinine tests. The complete blood count includes the hemoglobin analysis. All these values are within normal range, except the hemoglobin. If a client has a low hemoglobin level, the surgery may be postponed.

A client with heart disease who is taking digoxin (Lanoxin) complains of having no appetite. The nurse notes that the client also has a low serum potassium (K+) level. The nurse checks the results of the digoxin level obtained this morning, anticipating that the level will fit which characterization?

High Rationale: A high digoxin level would indicate digoxin toxicity, which is compatible with the client's complaint of anorexia and the low serum K+ level (which can precipitate digoxin toxicity). After drawing this initial conclusion, the next step would be for the nurse to notify the registered nurse or another health care provider for further action.

The nurse wants to ensure that the emergency department is prepared for a disaster and is creating an action plan for educating the staff. Which actions should the nurse plan in order to adequately prepare the staff? Select all that apply.

Identify specific nursing roles during a disaster. Test the disaster plans before a disaster occurs. Begin educating staff on roles at the time of a disaster. Encourage each nurse to create a personal emergency preparedness plan. Rationale: Disasters can happen at any time, without warning. Therefore, it is important that health care facilities have a plan in place. In order to adequately prepare staff for a disaster, the nurse manager should identify specific nursing roles, begin educating staff on what is expected of them during a disaster, test plans before a disaster occurs, and encourage nurses to create a personal emergency preparedness plan for themselves. The nurse manager should not wait until a disaster occurs to create a disaster plan because this can lead to inadequate resources for safe client care.

A client in labor is experiencing dystocia. In delivering care to this client, the nurse should place the highest priority on which ongoing nursing interventions?

Monitoring of the status of both mother and fetus Rationale: All of the options represent correct nursing actions, but the highest priority is to monitor the status of the mother and fetus. This option is the one that exemplifies the most urgent physiological need and, as such, takes precedence over the other nursing interventions.

A client with a history of gastrointestinal bleeding has a platelet count of 300,000 cells/mm3. Which action by the nurse is most appropriate after reading this report?

Place the normal report in the client's medical record. Rationale: A normal platelet count ranges from 150,000 to 400,000 cells/mm3. The nurse should place the report that contains the normal laboratory value into the client's medical record. The remaining options are incorrect and unnecessary.

A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client?

Private room within sight of the nurses' station Rationale: A quiet room in which stimuli can be minimized is most important, and so a private room within sight of the nurses' station is the correct option. The client will require constant monitoring, so the room farthest from the nurses' station is inappropriate. From the remaining options, rooms across from the elevator and the nurses' station have a high traffic flow and noise and would therefore be inappropriate.

A client is admitted to the hospital with a diagnosis of malnutrition. The nurse is told that blood will be drawn to determine whether the client has a protein deficiency. Which laboratory data indicates that the client is experiencing a protein deficiency?

Transferrin, 90 mg/dL Rationale: Serum transferrin is an iron transport protein that can be measured directly or calculated as an indirect measurement of total iron-binding capacity. It is a more sensitive indicator of protein status than albumin. When the serum transferrin level is less than 100 mg/dL, the level of visceral protein depletion is severe.

A CD4+ count has been prescribed for a child with human immunodeficiency virus (HIV) infection. The mother asks the nurse about the purpose of the test and why the test needs to be done if it is already known that the child has HIV. The nurse should reinforce which information to the mother? Select all that apply.

he CD4+ count is used to determine the child's immune status. The CD4+ count is used to identify the risk for disease progression. The CD4+ count identifies the need for Pneumocystis jiroveci pneumonia prophylaxis after 1 year of age. The CD4+ count is measured at ages 1 and 3 months, every 3 months until the age of 2 years, and at least every 6 months thereafter. More frequent monitoring of CD4+ counts is indicated when pneumonia prophylaxis and antiretroviral therapy are administered. Rationale: CD4+ counts are used to assess a young child's immune status, risk for disease progression, and need for pneumonia prophylaxis after 1 year of age. These counts are measured at ages 1 and 3 months, every 3 months until the age of 2 years, and at least every 6 months thereafter. More frequent monitoring of CD4+ counts is indicated when pneumonia prophylaxis and antiretroviral therapy are administered.

A client with a seizure disorder is taking phenytoin (Dilantin). A sample for a serum phenytoin level is drawn, and the nurse determines that the next dose of the medication may be administered if which laboratory result is noted?

17 mcg/mL Rationale: The therapeutic range for serum phenytoin (Dilantin) level is 10 to 20 mcg/mL, so the next dose of phenytoin should be given if the level is 17 mcg/mL. If the level is too high, such as in the remaining options, the client could experience phenytoin toxicity.

The nurse is monitoring the laboratory results of a client preparing to receive chemotherapy. The nurse determines that the white blood cell count (WBC) is normal if which result is present?

5000 cells/mm3 Rationale: The normal WBC count ranges from 4500 to 11,000 cells/mm3.

The nurse has received a 7 am change of shift report on four clients. Which client should the nurse check first?

A client admitted early this morning with right lower quadrant abdominal pain and an elevated leukocyte count Rationale: A client with right lower quadrant abdominal pain should be assessed first because these symptoms are commonly associated with acute appendicitis. A client who is to be discharged does not need to be checked first. A headache is common with head injuries, but the client is alert, indicating stability. A blood glucose of 180 mg/dL is of concern, but the client's blood glucose was likely much higher on admission and thus is more stable at this time.

The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)?

A client who requires a 24-hour urine collection Rationale: The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. The assignment of tasks needs to be implemented on the basis of the job description of the individual, the individual's level of clinical competence, and state law.

The nurse is caring for a client recovering from hepatitis. The nurse recognizes the need to report which laboratory test result to the health care provider?

Alanine aminotransferase (ALT) that is significantly elevated Rationale: As tissues in the body are injured, enzymes present in the cells are released and can be monitored through blood tests. It is important to recognize which enzymes are found in which tissues. ALT is found predominantly in the liver, and an elevated level would indicate significant liver damage. AST is found in high concentration in the heart muscle and is indicative of heart damage. Antigens are agents that trigger cell damage; antigens do not result from the damage.

A client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this result is most likely the result of which factor in the client's history?

Iron deficiency anemia Rationale: The normal hemoglobin level for an adult female client is 12 to 15 g/dL and 14 to 16.5 for a male client. A low hemoglobin level usually indicates anemia. Iron deficiency anemia can result in lower hemoglobin levels. Heart failure and COPD may increase the hemoglobin level as a result of the body's need for more oxygen-carrying capacity. Dehydration may increase the hemoglobin level by hemoconcentration.

A client was transferred to the nursing unit from the coronary care unit after experiencing a myocardial infarction (MI). When reviewing the client's serum creatinine phosphokinase (CPK) levels recorded in the chart, the nurse knows that an elevation of which enzyme was due to the MI?

MB Rationale: CPK is a cellular enzyme that can be fractionated into three isoenzymes. The MB band reflects CPK from cardiac muscle. This is the level that elevates with MI. The MM band reflects CPK from skeletal muscle. The BB band reflects CPK from the brain. There is no MK band.

A licensed practical nurse (LPN) is assisting in the care of a client receiving a continuous intravenous (IV) infusion of heparin sodium for deep vein thrombosis (DVT). The LPN notes that the result of a newly drawn activated partial thromboplastin time (aPTT) level is 90 seconds. The client's baseline before the initiation of therapy was 30 seconds. The LPN should take which action?

Notify the RN about the value immediately. Rationale: The normal aPTT varies between 20 and 36 seconds, depending on the type of activator used in testing. Heparin treatment for DVT aims to keep the aPTT between 1.5 and 2.5 times normal. Thus, the client's aPTT is elevated (75 is the upper therapeutic value for this client, given the baseline). The LPN should report the findings immediately to the RN, who will take further action to follow up on the elevated value. Option 4 puts the client at risk for bleeding.

The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of the tasks?

Perform follow-up with each staff member regarding the performance and outcome of the task. Rationale: The ultimate responsibility for a task lies with the person who delegated it. Therefore, it is the nurse's primary responsibility to follow up with each staff member regarding the performance of the task and the outcomes related to implementing the task. Not all staff members have the education, knowledge, and ability to make judgments about tasks being performed. The nurse documents that the task has been completed, but this would not be done until follow-up was implemented and outcomes were identified. It is not appropriate to assign the tasks that were not completed to the next nursing shift.

A licensed practical nurse (LPN) has been assigned to assist a community nurse, who is the leader of a task force, to identify interventions for teenagers from a local community who are abusing drugs. At the first meeting of the task force, the group members express concern that more information is needed to determine appropriate measures for the target teenagers. The LPN makes which suggestion to the community nurse to direct the group most effectively?

Prepare a survey that can be distributed to community members to determine their understanding of the drug abuse problem. Rationale: Option 4 is the only option that addresses the subject of the question and will identify the additional information required by the task force.

The nurse is reviewing the laboratory results from the lumbar puncture performed on a client with a diagnosis of meningitis. Which finding is indicative of a bacterial infection? Select all that apply.

Protein level of 20 mg/dL Increased white blood cells A cerebrospinal fluid (CSF) pressure of 250 mm H2O Rationale: If a bacterial infection of cerebrospinal fluid is present, test results will indicate a cloudy appearance, pressure greater than 200 mm H2O, protein greater than 15 mg/dL, increased white blood cells, and reduced glucose level.

The nurse determines that sodium polystyrene sulfonate (Kayexalate) has been effective in a client if which laboratory result is noted?

Serum potassium is 4.9 mEq/L. Rationale: The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L. Sodium polystyrene (Kayexalate) is a medication that is used to treat hyperkalemia. The laboratory values in the remaining options are slightly elevated; in addition, this medication would have no effect on these other electrolytes.

A client having preadmission testing before surgery has blood drawn for the determination of serum electrolyte levels. The nurse determines that which result warrants a call to the health care provider by the nurse?

Sodium, 148 mEq/L Rationale: The normal serum electrolyte ranges for adults are as follows: sodium, 135 to 145 mEq/L; potassium, 3.5 to 5.0 mEq/L; chloride, 98 to 107 mEq/L; and bicarbonate (venous), 22 to 29 mEq/L. The only abnormal value identified is the serum sodium level.

A client has just been treated with cardioversion. The nurse should check which measure first?

Status of airway Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway, however, is always the highest priority.

A nursing instructor asks a nursing student to identify situations that indicate a secondary level of prevention in health care. Which statement made by the student indicates a need for further study of the levels of prevention?

Teaching a stroke client how to use a walker Rationale: Secondary prevention focuses on the early diagnosis and prompt treatment of disease. Tertiary prevention is represented by rehabilitation services.

A client with diabetes mellitus calls the clinic nurse to report that the blood glucose level is 150 mg/dL. After obtaining further data from the client, the nurse determines that the client ate lunch approximately 2 hours ago. How should the nurse interpret the data?

The blood glucose level is slightly higher than the normal value. Rationale: Normal fasting blood glucose values range from 70 to 110 mg/dL, depending on health care provider preserence. The 2-hour postprandial blood glucose level should be less than 140 mg/dL. In this situation, the blood glucose value was 150 mg/dL 2 hours after the client ate, which is slightly elevated above normal. This value does not require health care provider notification.

A client with atrial fibrillation who is receiving maintenance therapy with warfarin sodium (Coumadin) has a prothrombin time (PT) of 30 seconds. The nurse anticipates that which will be prescribed?

Withholding the next dose of warfarin sodium Rationale: The normal PT is 9.6 to 11.8 seconds for the adult male and 9.5 to 11.3 seconds for the adult female. The goal of oral anticoagulation with warfarin sodium therapy is to achieve a PT at 1.5 to 2 times the laboratory control value. A PT of 30 seconds places the client at risk for bleeding, so the nurse should anticipate that the client would not receive further doses at this time. If the level is too high, the antidote (vitamin K) may be prescribed. The remaining options would make the client even more prone to bleeding.

The nurse in charge of a rehabilitation center is planning the client assignments for the day. Which client should the nurse assign to the unlicensed assistive personnel?

A client on strict bed rest and a 24-hour urine collection Rationale: The nurse is legally responsible for client assignments and must assign tasks based on the guidelines of nurse practice acts and the job description of the employing agency. A newly admitted client who had a below-the-knee amputation will require physiological and psychosocial care and initiation of rehabilitation. A client scheduled to be discharged home will require reinforcement of home care management. A client scheduled for a cardiac catheterization requires physiological needs. The nursing assistant has been trained to care for a client on bed rest and on urine collections. The nurse should provide instructions to the nursing assistant regarding the tasks, but the task required for this client is within the role description of a nursing assistant.

The nurse is planning the client assignments for the day. Which is an appropriate assignment for the unlicensed assistive personnel (UAP)?

A client who requires a 24-hour urine collection Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the appropriate assignment for a UAP would be to care for the client who requires urine collection. The client who has difficulty swallowing food and fluids is at risk for aspiration. Colostomy irrigations and tube feedings are not performed by unlicensed personnel.

The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)?

A client who requires frequent ambulation Rationale: The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the UAP would be to care for the client who requires frequent ambulation. The UAP is skilled in this task. The client who had a cardiac catheterization will require specific monitoring in addition to that of the vital signs. Wound irrigations and tube feedings are not performed by unlicensed personnel.

The nurse is reviewing the results of a client's serum laboratory studies. Which result indicates a deficiency of protein intake?

Albumin, 2.6 mg/dL Rationale: Albumin is a type of protein, and decreased serum levels (option 1) can indicate a number of problems, including malnutrition and decreased intake. The normal albumin level is 3.5 to 5 g/dL. The triglycerides, blood glucose, and hemoglobin levels are all within normal ranges. Triglycerides are one of the fatty acids, and glucose is the most elemental form of carbohydrate. Hemoglobin carries oxygen in the red blood cells.

A client will be undergoing a colonoscopy in the morning. Which task is appropriate to delegate to the unlicensed assistive personnel?

Answering the call light promptly after the enema has been given Rationale: Clients frequently have strong urges to defecate after receiving enemas and laxatives to prepare for the colonoscopy. It is not appropriate to provide a soft diet the evening before the exam; clear liquids only are provided. It is also inappropriate to delegate to the nursing assistant the responsibility to determine if the client understood instructions or to sign the procedure consent form. The unlicensed assistive personnel is trained to answer call lights.

The nurse is planning the client assignments. Which is the least appropriate assignment for the unlicensed assistive personnel (UAP)?

Assisting a child who is profoundly developmentally disabled to eat lunch Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the least appropriate assignment for the nursing assistant would be assisting with feeding a profoundly developmentally disabled child. The child is likely to have difficulty eating and therefore has a higher potential for complications, such as choking and aspiration. The remaining options do not include data indicating that these tasks carry any unforeseen risk.

The nurse is assisting in planning client assignments. Which is the least appropriate assignment for the unlicensed assistive personnel (UAP)?

Assisting a profoundly developmentally disabled child to eat lunch Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the least appropriate assignment for a nursing assistant would be assisting with feeding a profoundly developmentally disabled child. The child is likely to have difficulty eating, and therefore a higher potential for complications such as choking and aspiration exists. The three remaining options include no data that indicate that these tasks carry any unforeseen risk.

A client experiences a cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style?

Autocratic Rationale: Autocratic leadership is an approach in which the leader retains all authority and is primarily concerned with task accomplishment. It is an effective leadership style to implement in an emergency or crisis situation. The leader assigns clearly defined tasks and establishes one-way communication with the work group, and he or she makes all decisions independently. Situational leadership is a comprehensive approach that incorporates the leader's style, the maturity of the work group, and the situation at hand. Democratic leadership is a people-centered approach that is primarily concerned with human relations and teamwork. This leadership style facilitates goal accomplishment and contributes to the growth and development of the staff. Laissez-faire leadership is a permissive style in which the leader gives up control and delegates all decision making to the work group.

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory results warrant a call to the health care provider (HCP)? Select all that apply.

Calcium, 7 mg/dL Magnesium, 1 mg/dL White blood cells, 3000 cells/mm3 Rationale: The normal values include the following: white blood cells, 4500 to 11,000 cells/mm3; thyroid-stimulating hormone, 0.2 to 5.4 microunits/mL; magnesium, 1.6 to 2.6 mg/dL; calcium, 8.6 to 10.0 mg/dL; blood urea nitrogen, 5 to 20 mg/dL; and serum creatinine, 0.6 to 1.3 mg/dL. Therefore, values that are abnormal should be reported to the HCP.

A 7-year-old child is admitted to the pediatric unit with acute exacerbation of asthma due to infection. The health care provider has written the following prescriptions. In which priority order should the nurse implement the prescriptions? Arrange the actions in the order that they should be performed. All options must be used.

High-Fowler's position O2 via nasal cannula at 2 L/min Erythromycin ethylsuccinate (EryPed) 200 mg orally every 6 hours Chest x-ray Clear liquids PO as tolerated Rationale: Placing the child in high-Fowler's position first will assist in breathing. The oxygen can then be applied. Administering the antibiotic is the next priority. The chest x-ray should not be done until the child has had oxygen and the first dose of the antibiotic. The clear liquid diet is the last task to be performed.

The licensed practical nurse (LPN) employed in a long-term care facility is asked to assist in planning implementation of a change in the method of documentation system in the nursing unit. Many problems have occurred as a result of the present documentation system, and the nurse manager determines that a change is required. The LPN understands that which is the initial step in the process of change?

Identify the inefficiency that needs improvement or correction. Rationale: When beginning the change process, the nurse should identify and define the problem or the inefficiency that needs improvement or correction. This important first step can prevent many future problems because if the problem is not correctly identified, a plan for change may be aimed at the wrong problem. This is followed by goal setting, identifying potential solutions and strategies, and setting goals and priorities. The nurse then plans strategies to implement the change.

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which is a characteristic of this type of nursing model of practice?

Nursing staff are led by the nurse when providing care to a group of clients. Rationale: In team nursing, nursing personnel are led by the nurse when providing care to a group of clients.

A client with diabetes mellitus has a glycosylated hemoglobin A (HbA1c) level of 8%. Which instruction does the nurse plan to reinforce to the client based on this test result?

Prevent hyperglycemia. Rationale: Elevations of the HbA1c value indicate a need for teaching related to the prevention of hyperglycemic episodes. The HbA1c value measures the amount of glucose that has become permanently bound to the red blood cells. Elevations in blood glucose levels will cause elevations in the amount of glycosylation. Thus, this test is useful for detecting clients who have periods of hyperglycemia that are undetected in other ways. Values are expressed as a percentage of the total hemoglobin and based on the health care provider's preference, include the following: diabetic client with good control, 7.5% or less; diabetic client with fair control, 7.6% to 8.9%; and diabetic client with poor control, 9% or greater. Some health care providers prefer levels lower that these noted. Avoiding infection relates to a low white blood cell count rather than the HbA1c level. Taking in enough fluids relates to an increased hematocrit level rather than the HbA1c level. Increasing iron relates to a low red blood cell count and hemoglobin level rather than the HbA1c level. HbA1c relates to glucose.

The nurse is present at a disaster scene and is participating in the triage of victims. Which color tag should be assigned to a victim with evidence of open pneumothorax?

Red Rationale: An open pneumothorax can be a life-threatening situation unless immediately managed. The victim has a reasonable chance of survival if immediate treatment is instituted, so a red tag should be attached to the victim. Yellow tags are placed on victims whose injuries can wait for treatment without threat to life, for example, closed fractures. Green tags are placed on victims with minimal injury, for example, minor lacerations or those experiencing anxiety related to the disaster. Black tags are reserved for those who are dead or whose injuries are so extensive there is no chance of survival.

The nurse is reading a computer printout of the results of a cerebrospinal fluid (CSF) analysis performed on an adult client who underwent lumbar puncture. The nurse knows that a reported value of 0 is normal for which substance in CSF?

Red blood cells Rationale: The adult with normal CSF has no red blood cells in the CSF. The client may have small numbers of white blood cells (0 to 3 cells/mm3). Protein (15 to 45 mg/dL) and glucose (40 to 80 mg/dL) normally are present in CSF.

The nurse caring for a male client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's laboratory results and notes a hematocrit level of 30%. Which action should the nurse take?

Report the abnormally low level. Rationale: The normal hematocrit level in a male client ranges from 39% to 52%, depending on age. A hematocrit level of 30% is a low level and should be reported to the registered nurse and health care provider because it indicates blood loss.

A client arrives in the emergency department complaining of chest pain that began 4 hours ago. A troponin T blood specimen is obtained, and the results indicate a level of 0.6 ng/mL. How should the nurse correctly interpret these results?

The level is indicative of a myocardial infarction. Rationale: Troponins are regulatory proteins that are found in striated muscle. The troponins function together in the contractile apparatus for striated muscle in the skeletal muscle and the myocardium. Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. A troponin T level greater than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction. A normal troponin I level is less than 0.6 ng/mL, whereas a level greater than 1.5 ng/mL is consistent with a myocardial infarction. A troponin T level of 0.6 is not normal, so that option can be eliminated. Troponin T does not test for gastritis or angina, so those options can also be eliminated.

A client is seen in the urgent care center for complaints of chest pain 2 days ago. Since that time, the client has not been feeling well and fatigues easily. The nurse reviews the results of the laboratory tests and suspects myocardial infarction at the time of chest pain 2 days ago if which comes back positive?

Troponin I Rationale: Troponin I levels elevate as early as 3 hours after myocardial injury and may remain elevated for 7 to 10 days. The myoglobin level can rise as early as 2 hours after a myocardial infarction, with a rapid decline in the level seen after 7 hours. The CK level begins to rise within 6 hours of muscle damage, peaks at 18 hours, and returns to normal in 2 to 3 days. However, factors such as skeletal and cardiac muscle damage, as well as central nervous system damage, can lead to the elevation, so the total CK level is not specific enough. BNP is the primary marker for identifying heart failure.

The nurse is caring for a client with a diagnosis of gout. Which laboratory value should the nurse expect to note in the client?

Uric acid level of 8 mg/dL Rationale: In addition to its signs/symptoms, gout is diagnosed by the presence of persistent hyperuricemia, with the uric acid level higher than 7 mg/dL. Options 1, 3, and 4 indicate normal laboratory values. In addition, the presence of uric acid in an aspirated sample of synovial fluid confirms the diagnosis.