Nokea
A child is admitted to the hospital with a diagnosis of rheumatic fever. The nurse reviews the blood laboratory findings, knowing that which finding will confirm the likelihood of this disorder?
- A. Increased leukocyte count
- B. Decreased hemoglobin count
- C. Increased antistreptolysin-O (ASO titer)
- D. Decreased erythrocyte sedimentation rate
Correct Answer: C
Rationale: Children suspected of having rheumatic fever are tested for streptococcal antibodies. The most reliable and best standardized test to confirm the diagnosis is the ASO titer. An elevated level indicates the presence of rheumatic fever. The remaining options are unrelated to diagnosing rheumatic fever. Additionally, an increased leukocyte count indicates the presence of infection but is not specific in confirming a particular diagnosis.
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The nurse reviews a primary health care provider's prescriptions and notes that a topical nitrate is prescribed. The nurse notes that acetaminophen is prescribed to be administered before the nitrate. The nurse implements the prescription with which understanding about why acetaminophen is prescribed?
- A. Headache is a common side effect of nitrates.
- B. Fever usually accompanies myocardial infarction.
- C. Acetaminophen potentiates the therapeutic effect of nitrates.
- D. Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does.
Correct Answer: A
Rationale: Headache occurs as a side effect of nitrates in many clients. Acetaminophen may be administered before nitrates to prevent headaches or minimize the discomfort from the headaches.
After a client diagnosed with pleural effusion had a thoracentesis, a sample of fluid was sent to the laboratory. Analysis of the fluid reveals a high red blood cell count. Based on this test result, what was the cause of this client's pleural effusion?
- A. Trauma
- B. Infection
- C. Liver failure
- D. Heart failure
Correct Answer: A
Rationale: Pleural fluid from an effusion that has a high red blood cell count may result from trauma and may be treated with placement of a chest tube for drainage. Other causes of pleural effusion include infection, heart failure, liver or renal failure, malignancy, or inflammatory processes. Infection would be accompanied by white blood cells. The fluid portion of the serum would accumulate with liver failure and heart failure.
The nurse is caring for a client who has experienced a thoracic spinal cord injury. In the event that spinal shock occurs, which intravenous (IV) fluid should the nurse anticipate being prescribed?
- A. Dextran
- B. 0.9% normal saline
- C. 5% dextrose in water
- D. 5% dextrose in 0.9% normal saline
Correct Answer: B
Rationale: Normal saline 0.9% is an isotonic solution that primarily remains in the intravascular space, increasing intravascular volume. This IV fluid would increase the client's blood pressure. Dextran is rarely used in spinal shock because isotonic fluid administration is usually sufficient. Additionally, Dextran has potential adverse effects. Dextrose 5% in water is a hypotonic solution that pulls fluid out of the intravascular space and is not indicated for shock. Dextrose 5% in normal saline 0.9% is hypertonic and may be indicated for shock resulting from hemorrhage or burns.
The nurse provides dietary instructions to a client who needs to limit intake of sodium. The nurse instructs the client that which food items must be avoided because of their high sodium content? Select all that apply.
- A. Ham
- B. Apples
- C. Broccoli
- D. Soy sauce
- E. Asparagus
- F. Cantaloupe
Correct Answer: A,D
Rationale: Foods highest in sodium include table salt, some cheeses, soy sauce, cured pork, canned foods because of the preservatives, and foods such as cold cuts. Fruits and vegetables contain minimal amounts of sodium.
The nurse should place a client who sustained a head injury in which position to prevent increased intracranial pressure (ICP)?
- A. In left Sims' position
- B. In reverse Trendelenburg
- C. With the head elevated on a small, flat pillow
- D. With the head of the bed elevated at least 30 degrees
Correct Answer: D
Rationale: The client with a head injury is positioned to avoid extreme flexion or extension of the neck and to maintain the head in the midline, neutral position. The head of the bed is elevated to at least 30 degrees or as recommended by the primary health care provider. The client is log rolled when turned to avoid extreme hip flexion.