Nokea
A client is admitted to the ICU, which laboratory result must be reported immediately to the physician?
- A. Hematocrit 48%
- B. paCO2 38 mm Hg
- C. platelets 18,000
- D. WBC count 8000
Correct Answer: C
Rationale: A platelet count of 18,000 is significantly low, indicating a condition known as thrombocytopenia, which can lead to a risk of bleeding. In a critical care setting like the ICU, low platelet counts need to be addressed urgently to prevent serious complications such as hemorrhage. This result must be reported immediately to the physician so that appropriate interventions, such as transfusion of platelets, can be initiated promptly to manage the patient's condition effectively. Hematocrit, paCO2, and WBC count may also be important parameters to monitor in an ICU patient, but the critically low platelet count poses the most immediate threat to the patient's well-being and requires urgent attention.
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Blood and fluid loss from frequent diarrhea may cause hypovolemia and you can quickly assess volume depletion in Miss CC by:
- A. Measuring the quantity and specific gravity of her urine output
- B. Taking her blood pressure
- C. Comparing the patient's present weight with her last weight
- D. Administering the oral water test
Correct Answer: C
Rationale: Comparing the patient's present weight with her last weight is the best way to quickly assess volume depletion in Miss CC. As she has been experiencing frequent diarrhea leading to blood and fluid loss, changes in weight are a reliable indicator of changes in the body's fluid status. A significant decrease in weight would suggest a loss of fluid and potential hypovolemia due to the diarrhea. This method is simple, immediate, and directly reflects the impact of the fluid loss on the body's volume status. Measuring the quantity and specific gravity of her urine output could provide information on her kidney function but may not be as quick and direct in evaluating volume depletion as comparing her current weight with her last recorded weight. Taking her blood pressure is important in assessing overall cardiovascular status but may not be as immediate in reflecting the impact of fluid loss on volume status. Administering the oral water test is not a standard method for quickly assessing volume depletion in this scenario.
A nurse is teaching a parent about administration of iron supplements to a 7-month-old infant. Which should the nurse include in the teaching session? (Select all that apply.)
- A. Administer the iron supplement with a dropper toward the side and to the back of the mouth
- B. Administer the iron supplement with feedings.
- C. Your infant's stools may look tarry green.
- D. Your infant may have some diarrhea initially.
Correct Answer: A
Rationale: Administer the iron supplement with a dropper toward the side and to the back of the mouth: This instruction helps ensure that the iron supplement bypasses the taste buds on the front of the tongue, which may reduce the likelihood of a strong taste causing rejection or spitting out by the infant.
Kimberly, age 3 years, is being admitted for about 1 week of hospitalization. Her parents tell the nurse that they are going to buy her "a lot of new toys, because she will be in the hospital." The nurse's reply should be based on an understanding of which concept?
- A. New toys make hospitalization easier.
- B. New toys are usually better than older ones for children of this age.
- C. At this age, children often need the comfort and reassurance of familiar toys from home.
- D. Buying new toys for a hospitalized child is a maladaptive way to cope with parental guilt.
Correct Answer: C
Rationale: The correct response is based on the understanding that at the age of 3, children often find comfort and reassurance in familiar toys from home. This familiarity can help them cope with the stress and unfamiliar environment of being hospitalized. Introducing new toys may not provide the same level of comfort and may even add to the child's sense of disorientation during their stay in the hospital. It is essential to prioritize the child's emotional well-being and provide them with familiar items that can offer a sense of security during their hospitalization.
A client with a nagging cough makes an appointment to see the physician after reading that this symptom is one of the seven warning signs of cancer. What is another warning sign of cancer?
- A. Persistent nausea
- B. Indigestion
- C. Rash
- D. Chronic ache or pain
Correct Answer: D
Rationale: Chronic ache or pain is another warning sign of cancer. Persistent pain that does not go away and continues for weeks or months could be a symptom of cancer. It is important not to ignore persistent pain and to consult a healthcare provider if such pain exists, as it could be a sign of an underlying issue like cancer. Early detection and treatment are key in managing cancer and improving outcomes for patients.
The knows that a positive diagnosis for HIV infection is made based on; a.A history of high-risk sexual behaviors
- A. Positive ELISA and Western blot tests
- B. Evidence of extreme weight loss and high fever
- C. Identification of an associated opportunistic infection
Correct Answer: A
Rationale: The definitive diagnosis of HIV infection is made based on the detection of specific antibodies in the blood. The most commonly used tests for this purpose are ELISA (Enzyme-Linked Immunosorbent Assay) and Western blot. A positive result on both tests confirms the presence of HIV antibodies in the blood, indicating an active HIV infection. High-risk sexual behaviors, extreme weight loss, and opportunistic infections may raise suspicion for HIV infection, but a positive diagnosis is confirmed through specific laboratory tests like ELISA and Western blot.