Nokea
A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician?
- A. pH 7.39
- B. White blood cell (WBC) count 10,000 WBCs/mm3
- C. Hematocrit 60%
- D. Bleeding time of 4 minutes
Correct Answer: C
Rationale: Normal hematocrit in infant is 28%-42%. A 60% hematocrit may indicate polycythemia, a common complication of cyanotic heart disease.
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A client with a history of a stroke is receiving Plavix (clopidogrel). The nurse should monitor the client for:
- A. Bleeding
- B. Hypertension
- C. Hypoglycemia
- D. Fever
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet, increases bleeding risk, requiring monitoring for signs like bruising or epistaxis. Hypertension, hypoglycemia, and fever are not primary concerns.
A client had a myocardial infarction 5 days ago. His physician has ordered an echocardiogram to determine how his myocardial infarction has affected his ventricular wall motion. When the client asks if this test is painful, an appropriate response is:
- A. No, but you must be able to ride on a stationary bicycle while the test is being performed.
- B. No, but you will have to lie still and the gel that is used may be cool.
- C. Yes, but your physician will be there and will order pain medicine for you.
- D. Your physician has ordered medicine, which you will be given before you go for the test, which will make you sleepy.
Correct Answer: B
Rationale: An echocardiogram is non-invasive, requiring the client to lie still while cool gel is applied for ultrasound imaging, with no pain involved.
A client with AIDS tells the nurse that he has been using herbal supplements in addition to the regimen of drugs prescribed by the physician. The nurse should tell the client that:
- A. Most herbals are well suited to use with prescription medications.
- B. He should buy only FDA-approved herbal supplements for use.
- C. The use of herbals may alter the effect of the medication he is taking.
- D. The herbal supplements should be taken at the same time as his medication.
Correct Answer: C
Rationale: Herbal supplements can interact with antiretroviral drugs, altering their efficacy or toxicity (e.g., St. John’s wort reduces protease inhibitor levels). The nurse should advise the client to discuss herbals with the physician, as they are not inherently safe or FDA-regulated for this purpose.
The physician has diagnosed a client with cirrhosis characterized by asterixis. If the nurse assesses the client with asterixis, he can expect to find:
- A. Irregular movement of the wrist
- B. Enlargement of the breasts
- C. Dilated veins around the umbilicus
- D. Redness of the palmar surfaces
Correct Answer: A
Rationale: Asterixis, a flapping tremor of the wrists when extended, is a sign of hepatic encephalopathy in cirrhosis due to ammonia buildup. The other findings are unrelated to asterixis.
A client with a history of breast cancer is admitted with complaints of fatigue. The nurse should give priority to:
- A. Monitoring for anemia
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Fatigue in breast cancer may indicate anemia, so monitoring for anemia is the priority.