A client who had a plaster cast applied to the right arm 3 weeks ago presents to the clinic with an erythrocyte sedimentation rate (ESR) that has increased from 15 to 25 mm/hr. Which is the nurse's best action?
a. Repeat this laboratory assessment in 4 hours.
b. Have the cast reapplied.
c. Evaluate temperature and vital signs.
d. Obtain blood for a platelet count.
C
A rise in the ESR during fracture healing suggests a bone infection or a fat embolism. The nurse should collect all other assessment data that can assist in confirming this diagnosis and then should notify the health care provider. Repeating the laboratory assessment, reapplying the cast, and assessing a platelet count would not be indicated.
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You are the nurse caring for an elderly patient who is Asian-American who speaks little English. How would you assess this patient's pain?
A) Make a chart with English on one side and the patient's native language on the other so he can pick which word best describes his pain. B) Use the regular zero-to-ten pain scale C) Use the Faces Pain Scale D) Have a translator come in every time you assess the patient so you can document what the patient said
The nurse is assessing a client before surgery. Which assessments contraindicate the client having surgery as scheduled? (Select all that apply.)
a. Potassium level of 2.8 mEq/L b. International normalized ratio (INR) of 4 c. Prothrombin time (PTT) of 30 seconds d. Calcium level of 8.8 mEq/dL e. Positive pregnancy test f. Platelet count of 150,000
Which laboratory value is indicative of a "shift to the left"?
1. Increase in total white blood cell count 2. Increase in absolute neutrophils count (ANC) 3. Increase in platelets 4. Increase in erythrocytes
A nurse interviews a homeless parent with two teenage children. To best assess the family's use of resources, the nurse should ask:
a. "Can you describe a problem your family has successfully resolved?" b. "What community agencies have you found helpful in the past?" c. "What aspect of being homeless is most frightening for you?" d. "Do you feel you have adequate resources to survive?"