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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Showing the AP how to remove an indwelling urinary catheter may not provide sufficient evidence of their competency to perform the task safely and effectively. This approach assumes that observation alone is enough to determine competence, which is not necessarily the case. It's important to have a more structured assessment of the AP's skills.

Choice B rationale:

Reviewing the AP's skill competency checklist is the most appropriate action to ensure the AP is qualified to remove the indwelling urinary catheter. Competency checklists outline specific skills and steps required for a task, and they serve as a standardized way to assess the AP's capabilities. This process ensures that the AP has received proper training and has demonstrated competence before performing the procedure independently.

Choice C rationale:

Simply asking the AP if they know how to remove an indwelling urinary catheter is not a comprehensive method for verifying their qualifications. Self-assessment can be unreliable and may not accurately reflect the AP's actual skill level. Relying solely on self-reporting could compromise patient safety and quality of care.

Choice D rationale:

Pairing the newly hired AP with an experienced AP might provide some guidance, but it doesn't systematically assess the individual's competence. The level of experience of the experienced AP may vary, and their ability to teach or evaluate the new AP's skills may not be standardized.

A. Open the top flap of the sterile package towards the body. B. Maintain a 1.25 cm (0.5 in) border around the edges of the sterile field. C. Pick up the first sterile glove by grasping the folded cuff edge. D. Remove soiled dressings using sterile gloves.

Correct Answer is C

Explanation

The correct answer is choice c. Pick up the first sterile glove by grasping the folded cuff edge.

Choice A rationale:

Opening the top flap of the sterile package towards the body is incorrect. The top flap should be opened away from the body to maintain sterility and prevent contamination.

Choice B rationale:

Maintaining a 1.25 cm (0.5 in) border around the edges of the sterile field is correct practice, but it is not the specific action being asked about in this scenario.

Choice C rationale:

Picking up the first sterile glove by grasping the folded cuff edge is correct. This technique ensures that the outside of the glove remains sterile while putting it on.

Choice D rationale:

Removing soiled dressings using sterile gloves is incorrect. Soiled dressings should be removed using clean gloves to avoid contaminating the sterile gloves needed for the new dressing application.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse asks a newly hired assistive personnel (AP) to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take to ensure the AP is qualified to perform this task?

Correct Answer is B

Explanation

A nurse is observing a newly licensed nurse perform a sterile dressing change on a client who has a central venous catheter. Which of the following actions should the newly licensed nurse take?

Correct Answer is C

Explanation

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