Nokea
A client is admitted to the emergency department with a loss of consciousness with unknown etiology. The nurse expects to perform which laboratory test to assist in determining etiology?
- A. Total cholesterol
- B. Alkaline phosphatase
- C. Serum glucose
- D. Urinalysis
Correct Answer: C
Rationale: Serum glucose is critical to rule out hypoglycemia or hyperglycemia as causes of unconsciousness. Cholesterol (A), alkaline phosphatase (B), and urinalysis (D) are less urgent.
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The nurse is caring for a client with a history of asthma who is receiving Albuterol (Proventil). The nurse should monitor the client for:
- A. Tachycardia
- B. Hypotension
- C. Hypokalemia
- D. Hyperglycemia
Correct Answer: A
Rationale: Albuterol, a beta-agonist, commonly causes tachycardia as a side effect due to sympathetic stimulation. Hypotension, hypokalemia, and hyperglycemia are less frequent.
A female client is concerned that she is in a 'high-risk' group for the development of acquired immunodeficiency syndrome (AIDS). She wants to know about the advisability of donating blood. Which of the following responses is correct?
- A. Individuals who donate blood are at risk of getting the AIDS virus. You should not donate.'
- B. It's OK for you to donate because the blood bank has a test that is 100% effective.'
- C. You should not donate since it takes time to develop antibodies to the AIDS virus. If you donate blood before you develop the antibody, you could pass it on in the blood.'
- D. It is not a good idea for you to donate. If you have AIDS, the information is made public and could destroy your personal life.'
Correct Answer: C
Rationale: The AIDS virus cannot be transmitted to the donor through the blood donation procedure. The test for the AIDS virus is not absolutely foolproof; therefore, it is not wise for a person with known risk factors to donate blood. It takes time for antibodies to the AIDS virus to develop. An infected individual could donate contaminated blood without it testing positive for the virus. For reasons of confidentiality, information about individuals infected with AIDS is not made public.
Following a vaginal delivery, the postpartum nurse should observe for:
- A. Dystocia, kraurosis
- B. Chadwick's sign
- C. Fatigue, hemorrhoids
- D. Hemorrhage and infection
Correct Answer: D
Rationale: Hemorrhage and infection are critical complications to monitor post-vaginal delivery due to potential uterine or perineal issues.
The client has an order for Garamycin (gentamicin) to be administered. Which lab test should be done before beginning the medication?
- A. Hematocrit
- B. Serum creatinine
- C. White cell count
- D. BUN
Correct Answer: B
Rationale: Gentamicin, an aminoglycoside, is nephrotoxic. Serum creatinine is monitored before administration to assess baseline kidney function, as impaired renal function increases toxicity risk. Hematocrit, white cell count, and BUN are less specific for gentamicin.
The nurse is assessing a client with suspected tuberculosis. Which precaution should be implemented?
- A. Standard precautions
- B. Airborne precautions
- C. Droplet precautions
- D. Contact precautions
Correct Answer: B
Rationale: Tuberculosis is transmitted via airborne droplets, requiring airborne precautions (e.g., N95 mask, negative pressure room). Standard, droplet, and contact precautions are insufficient.