The nurse is caring for a client with a history of type 2 diabetes mellitus and hypertension who arrives at the clinic for a scheduled visit. Which finding requires further follow-up by the nurse?
Creatinine: Female: [0.5 to 1.1 mg/dL (44 to 97 µmol/L)], Male: [0.6 to 1.2 mg/dL (53 to 106 µmol/L)]

Blood pressure 130/80 mm Hg.

Serum creatinine 1.6 mg/dL (141.44 µmol/L).

Dark yellow urine.

Difficulty staying asleep.

Answer and Explanation

The Correct Answer is B

Choice A reason: A blood pressure of 130/80 mm Hg is considered high normal and may not require immediate follow-up for a patient with a history of hypertension.

Choice B reason: A serum creatinine of 1.6 mg/dL is above the normal range for both males and females, indicating possible kidney dysfunction, which requires further follow-up.

Choice C reason: Dark yellow urine could be a sign of dehydration, which is common in diabetes, but it is not as concerning as an elevated serum creatinine level.

Choice D reason: Difficulty staying asleep could be related to various factors and may require follow-up, but it is not as urgent as abnormal laboratory values.

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Correct Answer is D

Explanation

Choice A reason: Assessing for discomfort is important, but it is not a safety intervention that should be implemented during the creation of a sterile field.

Choice B reason: Instructing the client to keep hands under the sterile field is not practical or safe, especially since the client is mildly confused and may not be able to follow such instructions.

Choice C reason: Pouring cleansing solution onto the sterile cloth field is part of the debridement process but does not directly relate to client safety.

Choice D reason: Verifying informed consent is crucial for client safety to ensure that the client understands the procedure and agrees to it, especially when the client is confused.

A. Discuss that partners without similar symptoms may not be infected. B. Instruct the client on the importance of notifying sexual partners. C. Notify that persons with STIs are reported to local health departments. D. Provide counseling that most contraceptives protect against infection.

Correct Answer is B

Explanation

Choice A reason: Discussing symptomless partners may give false reassurance, as herpes can be transmitted even when symptoms are not present.

Choice B reason: Notifying sexual partners is crucial for public health and the prevention of further transmission of STIs.

Choice C reason: While it's true that STIs are reported, this does not provide the client with actionable advice for their situation.

Choice D reason: Most contraceptives do not protect against STIs like genital herpes, which is spread by skin-to-skin contact.

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Naxlex Comprehensive Predictor Exams

The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety?

Correct Answer is D

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

Correct Answer is B

Explanation

A client who is one day postpartum reports to the nurse that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

Patient Data Exhibits What can the nurse do to help the parents decrease their anxiety? Select all that apply.

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with a possible methicillin-resistant Staphylococcus aureus (MRSA) infection. What intervention(s) should the nurse include in the plan of care? Select all that apply.

A client with a history of rheumatic fever is diagnosed with mitral valve stenosis. The client has shortness of breath with exertion and fatigue. Which assessment finding warrants immediate intervention by the nurse?

A client has received a prescription for loratadine suspension, 10 mg to be taken orally once a day. The bottle is labeled as "Loratadine for Oral Suspension, USP 5 mg per 5 mL." How many teaspoons should the nurse instruct the client to take? (Please enter the numerical value only.)

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care?