A home health nurse is planning her daily visits and receives laboratory results for four adult clients. The nurse should first visit the client who has which of the following laboratory values?
Digoxin 1.0 ng/mL.
WBC 6,000/mm³.
Platelets 100,000/mm³.
Serum potassium 4.0 mEq/L.
The Correct Answer is C
Choice A rationale:
Digoxin is a medication used to treat heart conditions like heart failure and atrial fibrillation. A digoxin level of 1.0 ng/mL is within the therapeutic range (usually 0.5-2.0 ng/mL), indicating that the client's digoxin dosage is appropriate. However, this value doesn't indicate an urgent need for a home visit.
Choice B rationale:
A white blood cell count (WBC) of 6,000/mm³ falls within the normal range (typically 4,500-11,000/mm³). While this value could suggest a stable immune system, it doesn't provide information requiring immediate attention or a home visit.
Choice C rationale:
Platelets are essential for blood clotting. A platelet count of 100,000/mm³ is significantly below the normal range (usually 150,000-450,000/mm³), indicating a risk of bleeding and potentially a serious medical condition. This client is at risk for spontaneous bleeding and requires prompt assessment and intervention, making this choice the correct answer.
Choice D rationale:
A serum potassium level of 4.0 mEq/L falls within the normal range (typically 3.5-5.0 mEq/L). While maintaining electrolyte balance is important, this potassium level doesn't indicate an immediate need for a home visit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer is: d. "Clients are the experts on their own pain."
Explanation: The charge nurse's response acknowledges the client's self-report of pain, which is considered the most reliable indicator of pain presence and intensity. This approach emphasizes the importance of individualized pain management and respects the client's autonomy.
Statement a. is wrong because the nurse is suggesting an intervention without assessing the client's pain or consulting the healthcare provider. Although nonpharmacological interventions may be appropriate, they should be discussed with the client and provider before making decisions.
Statement b. is wrong because withholding prescribed medication without a valid reason or consultation with the healthcare provider is inappropriate and could result in inadequate pain management.
Statement c. is wrong because contacting mental health services for a consultation based on the assumption that the client is seeking drugs may be premature and overlook the client's reported pain. A thorough assessment and discussion with the healthcare provider should precede any consultation.
Correct Answer is A
Explanation
Choice A rationale:
Ethics committees are tasked with providing guidance and recommendations in ethical dilemmas. They don't make the final decisions, but rather facilitate discussions and help individuals involved in the situation to weigh the options and make informed choices. This is consistent with the committee's role in addressing complex ethical decisions.
Choice B rationale:
Providing a legal representative for the family is not the primary role of an ethics committee. Legal representation is a separate matter and might be considered in situations where there are legal implications, but the committee's primary function is to address ethical concerns and conflicts.
Choice C rationale:
While ethics committees can offer recommendations, their focus is not necessarily on determining the best course of action for the client. Instead, they help individuals explore ethical principles and values to make decisions that align with the client's best interests.
Choice D rationale:
The ethics committee does not make decisions on behalf of the nursing team. Its role is to provide guidance and promote ethical discussions. Deciding how the nursing team should resolve the dilemma is beyond the committee's scope.
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