A 57-year-old male client has hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse?
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Solution
Ask the client if he has noticed any bleeding or dark stools
Option A: Normal hemoglobin for males is 13.0 – 18 g/100 ml. Normal hematocrit for males is 42 – 52%. These values are below normal and indicate mild anemia. The first thing the nurse should do is ask the client if he’s noticed any bleeding or change in stools that could indicate bleeding from the GI tract.
Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing?
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Solution
“By prolonging breathing out with pursed lips my little areas in my lungs don’t collapse.”
Option D: Clients with chronic obstructive pulmonary disease have difficulty exhaling fully as a result of the weak alveolar walls from the disease process. Alveolar collapse can be avoided with the use of pursed-lip breathing. This is the major reason to use it.
Options A, B, and C: The other options are secondary effects of pursed-lip breathing.
For a 6-year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate?
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Solution
Institute seizure precautions
Option A: The severity of the acute phase of AGN is variable and unpredictable; therefore, a child with edema, hypertension, and gross hematuria may be subject to complications and anticipatory preparation such as seizure precautions are needed.
The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching?
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Solution
“I dip his pacifier in honey so he’ll take it.”
Option C: Honey has been associated with infant botulism and should be avoided. Older children and adults have digestive enzymes that kill the botulism spores.
A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?
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Solution
Sleep with head propped on several pillows
Option D: Heartburn is a burning sensation caused by regurgitation of gastric contents that is best relieved by sleeping position, eating small meals, and not eating before bedtime.
A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the health care provider ordering
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Solution
Vena caval interruption
Option B: Clients with contraindications to heparin, recurrent PE or those with complications related to the medical therapy may require vena caval interruption by the placement of a filter device in the inferior vena cava. A filter can be placed transvenously to trap clots before they travel to the pulmonary circulation.
The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?
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Solution
Temperature of 102.5 F
Option D: An adverse reaction of a fever should be reported immediately. Other reactions that should be reported include crying for > 3 hours, seizure activity, and tender, swollen, reddened areas.
The nurse is at the community center speaking with retired people. To which comment by one of the retirees during a discussion about glaucoma would the nurse give a supportive comment to reinforce correct information?
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Solution
“I take extra fiber and drink lots of water to avoid getting constipated.”
Option D: Any activity that involves straining should be avoided in clients with glaucoma. Such activities would increase intraocular pressure.
A 4-year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?
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Solution
Remove the child’s toys from the immediate area
Option D: Nursing care for a child having a seizure includes maintaining airway patency, ensuring safety, administering medications, and providing emotional support.
Options A and C: Since the seizure has already started, nothing should be forced into the child”s mouth and they should not be moved. Of the choices given, first priority would be for safety.
At a senior citizens meeting a nurse talks with a client who has diabetes mellitus Type 1. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity?
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Solution
“Sometimes when I put my shoes on I don’t know where my toes are.”
Option B: Peripheral neuropathy can lead to lack of sensation in the lower extremities. Clients do not feel pressure and/or pain and are at high risk for skin impairment.