Nokea
A 30-year-old woman is admitted to the hospital with complaints of severe abdominal cramping and diarrhea. The nurse evaluates the effectiveness of the patient's intravenous therapy. Which of the following laboratory tests BEST reflects hydration status?
- A. Erythrocyte sedimentation rate.
- B. White blood cell count.
- C. Hematocrit.
- D. Serum glucose.
Correct Answer: C
Rationale: The correct answer is C: Hematocrit. Hematocrit reflects the proportion of red blood cells in the blood and can indicate hydration status. When a person is dehydrated, their blood becomes more concentrated, leading to an increase in hematocrit levels. In this case, severe abdominal cramping and diarrhea can cause dehydration, making hematocrit the best indicator of hydration status.
Explanation for other choices:
A: Erythrocyte sedimentation rate is a nonspecific marker of inflammation and not directly related to hydration status.
B: White blood cell count is an indicator of infection or inflammation, not hydration status.
D: Serum glucose levels are related to blood sugar regulation, not hydration status.
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A nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The nurse assesses the client, knowing that which of the following is a hallmark sign of this disorder?
- A. Severe abdominal pain relieved by vomiting
- B. Severe abdominal pain that is unrelieved by vomiting
- C. Hypothermia
- D. Epigastric pain radiating to the neck area
Correct Answer: B
Rationale: The correct answer is B: Severe abdominal pain that is unrelieved by vomiting. In acute pancreatitis, the pancreatic enzymes cause inflammation and damage to the pancreas, leading to severe abdominal pain that is typically constant and not relieved by vomiting. Vomiting may even worsen the pain. Other choices are incorrect because severe abdominal pain in acute pancreatitis is not relieved by vomiting (A), hypothermia is not a hallmark sign of acute pancreatitis (C), and epigastric pain radiating to the neck area is not a specific hallmark sign (D).
The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse makes which statement to the client?
- A. Take a deep breath when I tell you and breathe normally while I remove the tube.
- B. Take a deep breath when I tell you and bear down while I remove the tube.
- C. Take a deep breath when I tell you and slowly exhale while I remove the tube.
- D. Take a deep breath when I tell you and hold it while I remove the tube.
Correct Answer: C
Rationale: The correct answer is C because instructing the client to take a deep breath and slowly exhale while the tube is being removed helps relax the client's throat muscles, making the removal process smoother and less uncomfortable. Taking a deep breath and holding it (choice D) could lead to increased tension and resistance, while bearing down (choice B) may cause the client to push against the tube, making the removal difficult. Instructing the client to breathe normally (choice A) doesn't provide specific guidance on how to facilitate the removal process.
A nurse is caring for a client who has just returned from the operating room following the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is most appropriate based on this assessment?
- A. Notify the physician
- B. Document the amount and characteristics of the drainage
- C. Apply ice to the stoma site
- D. Apply pressure to the site
Correct Answer: B
Rationale: The correct answer is B: Document the amount and characteristics of the drainage. This is appropriate as serosanguineous drainage is expected after colostomy creation. Documenting helps monitor for any changes and provides crucial information for the healthcare team.
Choice A (Notify the physician) is not necessary at this point as serosanguineous drainage is normal postoperatively. Choice C (Apply ice to the stoma site) and Choice D (Apply pressure to the site) are both incorrect actions that are not indicated in this situation and could potentially harm the client.
A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that because the stomach lining produces a decreased amount of intrinsic factor in this disorder, the client will need
- A. Vitamin B12 injections.
- B. Vitamin B6 injections.
- C. An antibiotic.
- D. An antacid.
Correct Answer: A
Rationale: The correct answer is A: Vitamin B12 injections. Pernicious anemia results from a lack of intrinsic factor, which is necessary for the absorption of vitamin B12 in the intestines. Therefore, the client with this disorder will need vitamin B12 injections to bypass the need for intrinsic factor.
Choice B (Vitamin B6 injections) is incorrect because pernicious anemia specifically involves a deficiency in vitamin B12, not B6. Choice C (An antibiotic) is incorrect as antibiotics are not indicated for pernicious anemia. Choice D (An antacid) is also incorrect as it does not address the underlying issue of vitamin B12 deficiency caused by the lack of intrinsic factor.
The nurse is assessing a 71-year-old female client with ulcerative colitis. Which assessment finding related to the family will have the greatest impact on the client's rehabilitation after discharge?
- A. The family's ability to take care of the client's special diet needs
- B. The family's expectation that the client will resume responsibilities and role-related activities
- C. Emotional support from the family
- D. The family's ability to understand the ups and downs of the illness
Correct Answer: C
Rationale: The correct answer is C because emotional support from the family is crucial for the client's rehabilitation. Emotional support can positively impact the client's mental health, motivation, and adherence to treatment plans. It can also reduce stress and anxiety, which are common in chronic illnesses like ulcerative colitis. Options A and D focus on practical aspects and understanding of the illness, which are important but not as impactful as emotional support. Option B addresses the client's responsibilities, which, while important, may not have as direct an impact on rehabilitation as emotional support.