Nokea
A client has entered disseminated intravascular coagulation (DIC) after becoming extremely ill after surgery. Which of the following laboratory findings would the nurse expect to see with this client?
- A. Elevated fibrinogen level
- B. Prolonged PT
- C. Elevated platelet count
- D. Depressed d-dimer level
Correct Answer: B
Rationale: In disseminated intravascular coagulation (DIC), a client experiences widespread clotting throughout the body, leading to the depletion of clotting factors and platelets. A prolonged prothrombin time (PT) is a common finding in DIC. The PT measures the extrinsic pathway of the clotting cascade and reflects how quickly blood can clot. In DIC, the consumption of clotting factors results in a prolonged PT, indicating impaired clotting ability. Elevated fibrinogen levels (Choice A) are typically seen in the early stages of DIC due to the body's attempt to compensate for clot breakdown. Elevated platelet count (Choice C) is not a typical finding in DIC as platelets are consumed during the widespread clotting. A depressed d-dimer level (Choice D) is also not expected in DIC as d-dimer levels are elevated due to the breakdown of fibrin clots. Therefore, the correct answer is a prolonged PT.
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A client is receiving education on cholesterol. Which of the following statements from the client indicates the need for further teaching?
- A. I would like my HDL levels to be over 50.
- B. It is better for me to have high HDL levels and low LDL levels.
- C. It is better for me to have high LDL levels and low HDL levels.
- D. My goal is to get my total cholesterol below 200.
Correct Answer: C
Rationale: The correct answer is, 'It is better for me to have high LDL levels and low HDL levels.' This statement indicates a need for further teaching because high LDL levels contribute to atherosclerosis, while high HDL levels can protect against heart disease. The client should understand the importance of lowering LDL levels and increasing HDL levels to maintain good heart health. Choice A is correct as desiring HDL levels over 50 is a positive goal. Choice B is correct as it reflects the ideal scenario of high HDL and low LDL levels. Choice D is correct as a total cholesterol below 200 is a common goal for heart health. Therefore, Choice C is incorrect as it suggests an opposite and unhealthy relationship between LDL and HDL levels.
The nurse caring for a client in labor should plan to assess the fetal heart rate (FHR) at which specific times? Select all that apply.
- A. Before ambulation
- B. After vaginal examination
- C. After rupture of the membranes
- D. Before turning the client on her side
- E. Before the administration of oxytocin
Correct Answer: A,B,C,E
Rationale: Assessment of the mother and fetus is continuous during the process of labor. However, for all clients, the FHR needs to be assessed before ambulation; immediately after vaginal examinations, rupture of the membranes, or any other invasive procedure; and before the administration of oxytocin because these activities or situations can cause alterations in the FHR. The FHR is also assessed in between contractions, during the contraction, and for at least 30 seconds after the contraction. It is not necessary to assess the FHR before turning the client to her side.
Mr. Y had surgery two days ago and is recovering on the surgical unit of the hospital. Just before lunch, he develops chest pain and difficulties with breathing. His respiratory rate is 32/minute, his temperature is 100.8°F, and he has rales on auscultation. Which of the following nursing interventions is most appropriate in this situation?
- A. Place the client in the Trendelenburg position
- B. Contact the physician for an order for antibiotics
- C. Administer oxygen therapy
- D. Decrease his IV rate
Correct Answer: C
Rationale: Chest pain, dyspnea, tachypnea, mild fever, and rales or crackles on auscultation in a client who had surgery 2 days ago may be indicative of a pulmonary embolism. The nurse should administer oxygen to address his breathing and assist him to a comfortable position to facilitate better oxygenation before contacting the physician. Placing the client in the Trendelenburg position is not recommended in this situation as it may worsen a potential pulmonary embolism by increasing venous return. Contacting the physician for antibiotics is not the priority as the immediate concern is addressing the breathing difficulty. Decreasing the IV rate is not indicated in this situation where the client is experiencing respiratory distress and needs oxygen therapy.
While caring for a client who has just come from surgery and is in the recovery room with an endotracheal tube in place, the nurse deflates the cuff on the tube and removes it. The client sits up in bed, grasps his throat, and begins to make wheezing sounds. Which of the following conditions is the most likely cause of this situation?
- A. The client is choking on part of the tube
- B. The client has anxiety
- C. The client is having a laryngospasm
- D. The client is having a normal response from anesthesia
Correct Answer: D
Rationale: After surgery, some clients may experience a laryngospasm during emergence from anesthesia. A laryngospasm can lead to the closure of the laryngeal opening due to spasm of the vocal cords. In this scenario, the client's symptoms of wheezing and throat grasping are indicative of a laryngospasm rather than choking on the tube, anxiety, or a normal response from anesthesia. The nurse should act promptly to open the airway to aid breathing and consider administering muscle relaxants as necessary.
The nurse is teaching the client about smoking cessation. Which client statement indicates a need for further teaching by the nurse?
- A. Social smoking can still be detrimental to my health.
- B. E-cigarettes can help me wean off nicotine so I can quit.
- C. Pack years are calculated by my packs per day multiplied by the number of years I've smoked.
- D. Nicotine replacement therapy along with a smoking cessation program is the most successful treatment.
Correct Answer: B
Rationale: E-cigarettes are not FDA-approved for smoking cessation and may still pose health risks. Other statements are accurate.