Nokea
A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following?
- A. Hypernatremia
- B. Hypokalemia
- C. Myelosuppression
- D. Leukocytosis
Correct Answer: B
Rationale: A potassium level of 1.9 mEq/L indicates hypokalemia, which is a critical electrolyte imbalance.
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The nurse is reviewing the lab results of four clients. Which finding should be reported to the physician?
- A. A client with chronic renal failure with a serum creatinine of 5.6 mg/dL
- B. A client with rheumatic fever with a positive C reactive protein
- C. A client with gastroenteritis with a hematocrit of 52%
- D. A client with epilepsy with a white cell count of 3,800 mm³
Correct Answer: C
Rationale: A hematocrit of 52% in gastroenteritis suggests dehydration, which requires immediate reporting.
A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client's symptoms are consistent with a diagnosis of:
- A. Pneumonia
- B. Reaction to antiviral medication
- C. Tuberculosis
- D. Superinfection due to low CD4 count
Correct Answer: C
Rationale: The symptoms of low-grade fever, blood-tinged hemoptysis, fatigue, and night sweats are classic for tuberculosis.
The nurse is seeing a client and her 11-month-old baby in the clinic for a wellness checkup. Which comment by the mother would prompt the nurse to notify the health care provider?
- A. She loves to play peekaboo.
- B. She loves to look at herself in the mirror.
- C. She does not like to be around strangers.
- D. She does not try to crawl when I put her down.
Correct Answer: D
Rationale: Lack of crawling at 11 months may indicate developmental delay, requiring provider evaluation. Other behaviors are age-appropriate.
A client with a right lobectomy is being transported from the intensive care unit to a medical unit. The nurse understands that the client's chest drainage system:
- A. Can be disconnected from suction if the chest tube is clamped
- B. Can be disconnected from suction, but the chest tube should remain unclamped
- C. Must remain connected by means of a portable suction
- D. Must be kept even with the client's shoulders during the transport
Correct Answer: B
Rationale: The chest tube should remain unclamped and disconnected from suction during transport to prevent tension pneumothorax, with the system kept below chest level.
Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:
- A. Utilizes a Steinman pin
- B. Requires that both legs be secured
- C. Utilizes Kirschner wires
- D. Is used primarily to heal the fractured hips
Correct Answer: A
Rationale: Balanced skeletal traction commonly uses a Steinman pin to stabilize fractures.