Nokea
A client is admitted with acute pancreatitis. The nurse should monitor which of the following laboratory values?
- A. Decreased urine amylase level.
- B. Increased calcium level.
- C. Decreased glucose level.
- D. Increased serum amylase and lipase levels.
Correct Answer: D
Rationale: Acute pancreatitis causes elevated serum amylase and lipase due to pancreatic enzyme release, key diagnostic markers.
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The mother of a neonate delivered at 36 weeks' gestation asks why the neonate is being treated for sepsis when no infection is present. Which of the following responses by the nurse is most appropriate?
- A. The neonate may have an infection that we haven't identified yet.'
- B. Premature neonates are more susceptible to infections.'
- C. This is a precautionary measure because the neonate is premature.'
- D. Antibiotics are given to all neonates born before 37 weeks.'
Correct Answer: C
Rationale: Treating a 36-week neonate for sepsis is often precautionary due to their increased risk of infection, even without confirmed infection, to prevent complications.
The nurse is caring for a neonate with respiratory distress syndrome. Which intervention should the nurse anticipate?
- A. Administer surfactant
- B. Provide high-flow oxygen
- C. Initiate antibiotic therapy
- D. Perform chest physiotherapy
Correct Answer: A
Rationale: Surfactant administration is the primary treatment for respiratory distress syndrome in neonates, improving lung compliance and oxygenation.
When obtaining the nursing history of a client who has diabetes mellitus, the nurse should assess the client for which of the following early symptom of renal insufficiency?
- A. Polyuria
- B. Oliguria
- C. Anuria
- D. Dysuria
Correct Answer: A
Rationale: Polyuria is an early symptom of renal insufficiency in diabetes due to impaired kidney function affecting urine concentration. Oliguria, anuria, and dysuria are later or less specific.
The nurse performing tracheostomy care has replaced the tracheostomy tube holder (tracheostomy ties). Which is an effective measure for the nurse to use when determining if the holder is not too tight?
- A. The client nods that he or she feels comfortable.
- B. Two fingers can be slid comfortably under the holder.
- C. Four fingers can be slid comfortably under the holder.
- D. The tracheostomy does not move more than 0.5 inch when the client coughs.
Correct Answer: B
Rationale: There should be enough room for two fingers to slide comfortably under the tracheostomy holder. This ensures that the holder is tight enough to prevent tracheostomy dislocation, while preventing excessive constriction around the neck. The other options are incorrect.
A client with a history of chronic kidney disease is admitted with anemia. The nurse should expect to administer which of the following medications?
- A. Epoetin alfa (Epogen).
- B. Ferrous sulfate.
- C. Vitamin B12.
- D. Folic acid.
Correct Answer: A
Rationale: Epoetin alfa stimulates red blood cell production in chronic kidney disease-related anemia.