Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reviewing laboratory values for a client who is at 34 weeks of gestation. Which of the following findings should the nurse report to the provider?
A. Hgb 13.2 g/dL
Hgb (hemoglobin) of 13.2 g/dL is within the normal range for pregnancy.
B. BUN 15 mg/dL
BUN (blood urea nitrogen) of 15 mg/dL is within the normal range, indicating normal kidney function.
C. Urine protein 3+
Proteinuria can indicate kidney dysfunction or potential complications in pregnancy, such as preeclampsia. The provider needs to be aware of this finding and may want to assess the client further and consider appropriate interventions.
D. Fasting blood glucose 72 mg/dL
Fasting blood glucose of 72 mg/dL is within the normal range and indicates normal blood sugar levels.
This question is an excerpt from Nurse Dive's nursing test bank - PN Comprehensive Predictor PN 2020 Proctored Exam. Take the full exam now
Full Explanation
Proteinuria can indicate kidney dysfunction or potential complications in pregnancy, such as preeclampsia. The provider needs to be aware of this finding and may want to assess the client further and consider appropriate interventions.
The other laboratory values are within normal ranges and do not require immediate reporting. Hgb (hemoglobin) of 13.2 g/dL is within the normal range for pregnancy. BUN (blood urea nitrogen) of 15 mg/dL is within the normal range, indicating normal kidney function. Fasting blood glucose of 72 mg/dL is within the normal range and indicates normal blood sugar levels.
Similar Questions
A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?
A. Assign the client to a negative pressure airflow room
Assigning the client to a negative pressure airflow room is not necessary unless the client has a compromised immune system or is experiencing severe respiratory symptoms.
B. Have visitors remain at least 0.91 m (3 feet) away from the client
Having visitors remain at least 0.91 m (3 feet) away from the client is not sufficient to prevent the spread of the virus.
C. Administer aspirin if the client develops a fever
Administering aspirin to a client with varicella zoster is contraindicated because it can increase the risk of developing Reye's syndrome, a potentially fatal condition.
D. Initiate contact precautions for the client
Varicella zoster, also known as chickenpox, is a highly contagious viral infection that can be spread through contact with respiratory secretions or fluid from the vesicular rash. Contact precautions include wearing gloves and gown when in contact with the client or any potentially contaminated surfaces or materials, and isolating the client in a private room if possible.
Full Explanation
Varicella zoster, also known as chickenpox, is a highly contagious viral infection that can be spread through contact with respiratory secretions or fluid from the vesicular rash.
Contact precautions include wearing gloves and gown when in contact with the client or any potentially contaminated surfaces or materials, and isolating the client in a private room if possible.
Assigning the client to a negative pressure airflow room is not necessary unless the client has a compromised immune system or is experiencing severe respiratory symptoms.
Having visitors remain at least 0.91 m (3 feet) away from the client is not sufficient to prevent the spread of the virus.
Administering aspirin to a client with varicella zoster is contraindicated because it can increase the risk of developing Reye's syndrome, a potentially fatal condition.
A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
A. Turn the child onto their back.
It is important not to turn the child onto their back during a seizure, as this can obstruct the airway and potentially lead to respiratory distress.
B. Restrain the child's upper extremities.
Restraining the child's upper extremities is also not recommended, as it can cause injury to the child or the person trying to restrain them.
C. Place a padded tongue blade in the child's mouth.
Placing a padded tongue blade or any object in the child's mouth is no longer recommended during a seizure. Doing so can cause injury to the child's mouth or teeth and is not necessary for seizure management.
D. Place a pillow under the child's head.
The correct action to take in this situation is to place a pillow or cushion under the child's head. This will help protect the child from injuring their head during the seizure.
Full Explanation
The correct action to take in this situation is to place a pillow or cushion under the child's head.
This will help protect the child from injuring their head during the seizure.
It is important not to turn the child onto their back during a seizure, as this can obstruct the airway and potentially lead to respiratory distress.
Restraining the child's upper extremities is also not recommended, as it can cause injury to the child or the person trying to restrain them.
Placing a padded tongue blade or any object in the child's mouth is no longer recommended during a seizure. Doing so can cause injury to the child's mouth or teeth and is not necessary for seizure management.
A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan?
A. Restrict the client's sodium intake to 3 g per day.
Sodium restriction is a key component in the management of ascites, as it helps to reduce fluid retention. However, the standard recommendation for sodium intake in ascites management is typically lower than 3 grams per day. The guideline is often around 2 grams or even less to effectively manage ascites. Thus, while the concept is correct, the specific amount in this option is slightly higher than usually recommended.
B. Position the client supine with legs elevated.
This is not generally recommended for clients with ascites. Lying flat can increase discomfort and pressure on the diaphragm, making breathing more difficult. Instead, positioning the client in a semi-Fowler's or Fowler's position can help alleviate respiratory distress by reducing pressure on the diaphragm.
C. Measure the client's abdominal girth daily.
This is a crucial intervention. Measuring abdominal girth daily provides a reliable way to monitor changes in the size of the abdomen, which reflects changes in the amount of ascitic fluid. It helps in assessing the effectiveness of treatment and detecting any rapid accumulation of fluid that might require intervention.
D. Keep the client's daily protein intake below 0.8 g/kg.
While protein restriction was traditionally recommended to prevent hepatic encephalopathy, more recent guidelines suggest that moderate protein intake should be maintained unless the client has severe hepatic encephalopathy. Adequate protein intake is necessary to prevent muscle wasting and support liver function, and it should generally be individualized based on the client’s condition.
Full Explanation
A. Sodium restriction is a key component in the management of ascites, as it helps to reduce fluid retention. However, the standard recommendation for sodium intake in ascites management is typically lower than 3 grams per day. The guideline is often around 2 grams or even less to effectively manage ascites. Thus, while the concept is correct, the specific amount in this option is slightly higher than usually recommended.
B. This is not generally recommended for clients with ascites. Lying flat can increase discomfort and pressure on the diaphragm, making breathing more difficult. Instead, positioning the client in a semi-Fowler's or Fowler's position can help alleviate respiratory distress by reducing pressure on the diaphragm.
C. This is a crucial intervention. Measuring abdominal girth daily provides a reliable way to monitor changes in the size of the abdomen, which reflects changes in the amount of ascitic fluid. It helps in assessing the effectiveness of treatment and detecting any rapid accumulation of fluid that might require intervention.
D. While protein restriction was traditionally recommended to prevent hepatic encephalopathy, more recent guidelines suggest that moderate protein intake should be maintained unless the client has severe hepatic encephalopathy. Adequate protein intake is necessary to prevent muscle wasting and support liver function, and it should generally be individualized based on the client’s condition.