While assisting with a lumbar puncture, the nurse determines that a patient's cerebrospinal (CSF) fluid is normal. What did the nurse assess to make this clinical decision?
1. The CSF is yellow, without sediment.
2. The CSF is tinged with blood but has no sediment.
3. The CSF is clear and colorless.
4. The CSF is pink, without sediment.
Correct Answer: 3
Normal CSF is clear and colorless, not yellow, blood-tinged, or pink.
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A nurse is discharging parents and their new infant. When assisting the family to place the infant in a car seat, which observation leads the nurse to reinforce teaching?
A. The baby is wearing a sack-type sleeper. B. The baby is wearing a single layer of clothes. C. The parent checks the temperature of the car seat. D. A rear-facing car seat is in the back seat.
One bed is available for admitting a client with an eating disorder. Of the following clients, who
should be admitted? The client whose weight dropped from a. 150 to 100 pounds over a 4-months period, with the following vital signs: temperature, 35.9° C; pulse, 38 beats/min; blood pressure, 60/40 mm Hg. b. 120 to 90 pounds over a 3-month period, with the following vital signs: temperature, 36° C; pulse, 50 beats/min; blood pressure, 70/50 mm Hg. c. 110 to 70 pounds over a 4-month period, with the following vital signs: temperature 36.5° C; pulse, 60 beats/min; blood pressure, 80/66 mm Hg. d. 90 to 78 pounds over a 5-month period, with the following vital signs: temperature, 36.7° C; pulse, 62 beats/min; blood pressure, 74/48 mm Hg.
What instructions should the nurse provide to a client at risk of deep vein thrombosis who is being discharged home with low–molecular weight heparin?
A. "You must have your aPTT checked every 2 weeks." B. "Massage the injection site after the heparin is expelled." C. "Notify your health care provider if your stools appear tarry." D. "You will have a heparin lock placed before discharge for injection of the medi-cation."
The nurse is caring for a patient recovering from a splenectomy. What should the nurse realize will occur regarding this patient's immunity?
1. The liver and bone marrow will take over the spleen's functions. 2. The patient will need to avoid infections every day of his life. 3. The patient will have edematous lymph glands throughout his body. 4. The thymus gland will take over the spleen's functions.