Nokea
A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?
- A. Elevated blood glucose
- B. Elevated platelet count
- C. Elevated creatinine clearance
- D. Elevated liver enzymes
Correct Answer: D
Rationale: HELLP syndrome (Hemolysis Elevated Liver enzymes Low Platelets) is characterized by elevated liver enzymes reflecting liver damage. Platelet counts are low not elevated and blood glucose and creatinine clearance are not primary features.
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Why is Phytonadione (vitamin K) administered to a newborn shortly after birth?
- A. To stop hemorrhage
- B. To treat infection
- C. To replace electrolytes
- D. To facilitate clotting
Correct Answer: D
Rationale: Newborns have low vitamin K levels, necessary for clotting factor synthesis. Phytonadione is given to facilitate clotting and prevent hemorrhagic disease of the newborn. It does not stop active hemorrhage, treat infections, or replace electrolytes.
A client with cancer is experiencing a common side effect of chemotherapy administration. Which laboratory assessment finding would cause the most concern?
- A. A sodium level of 50 mg/dL
- B. A blood glucose of 110 mg/dL
- C. A platelet count of 125,000/mm3
- D. A white cell count of 5,000/mm3
Correct Answer: A
Rationale: A sodium level of 50 mg/dL is impossible (likely a typo for 50 mEq/L, which is severely hyponatremic) and life-threatening, causing seizures. Glucose (B), platelets (C), and WBC (D) are near normal or less critical.
The client is diagnosed with a pneumothorax. Which finding is most expected on auscultation?
- A. Bilateral crackles
- B. Diminished breath sounds on the affected side
- C. Wheezing throughout lung fields
- D. Rhonchi in the lower lobes
Correct Answer: B
Rationale: A pneumothorax causes collapsed lung tissue, resulting in diminished or absent breath sounds on the affected side. Crackles, wheezing, and rhonchi are not typical.
The nurse is teaching the client with AIDS regarding needed changes in food preparation. Which statement indicates that the client understands the nurse's teaching?
- A. Adding fresh ground pepper to my food will improve the flavor.
- B. Meat should be thoroughly cooked to the proper temperature.
- C. Eating cheese and yogurt will prevent AIDS-related diarrhea.
- D. It is important to eat four to five servings of fresh fruits and vegetables a day.
Correct Answer: B
Rationale: Thoroughly cooking meat reduces the risk of foodborne infections, which is critical for clients with AIDS due to their compromised immune systems.
A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The nursing assessment of arterial blood gases indicate the presence of:
- A. Respiratory alkalosis
- B. Respiratory acidosis
- C. Metabolic alkalosis
- D. Metabolic acidosis
Correct Answer: D
Rationale: Metabolic acidosis is determined by low pH and HCO3.