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
Choice A rationale:
A nurse cannot provide basic treatment information to the client's employer without the client's explicit consent. This information falls under the client's confidentiality rights and cannot be shared without proper authorization.
Choice B rationale:
While a nurse can inform the client about the risks and benefits of electroconvulsive therapy, this statement does not encompass the entirety of the client's rights. Clients have the right to be informed about the risks and benefits of all treatments, not just electroconvulsive therapy.
Choice C rationale:
Clients on a mental health unit who are admitted voluntarily have the right to leave against medical advice, as long as they are deemed capable of making that decision. Voluntary admission does not negate a client's autonomy to make decisions about their own care.
Choice D rationale:
The correct answer. Clients on a mental health unit have the right to refuse their medication, as long as they are deemed competent to make that decision. This is an important aspect of respecting a client's autonomy and informed consent, even in a mental health setting. However, if a client's refusal poses a serious risk to their health or the health of others, healthcare providers may need to take appropriate actions while respecting legal and ethical standards.
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
“A client who is in balanced skeletal traction.” This client requires specialized orthopedic knowledge to manage the traction and monitor for complications. A nurse without orthopedic experience may not be familiar with the care required.
Choice B rationale:
“A client who had a total hip arthroplasty 3 days ago.” This client is likely to require specialized post-operative care, including pain management, mobility assistance, and monitoring for complications such as infection or dislocation. These tasks typically require specific orthopedic training.
Choice C rationale:
“A client who has a fractured femur with a new cast.” This client will require specialized care to manage the cast, monitor for complications such as compartment syndrome, and provide pain management. These tasks typically require specific orthopedic training.
Choice D rationale:
“A client who had a right above-the-knee amputation 24 hours ago.” This is the correct answer. While this client will require post-operative care, the care is likely to be similar to the post-operative care provided on a medical unit, such as pain management, wound care, and monitoring for complications. Therefore, a nurse from a medical unit could likely provide appropriate care for this client.
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