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A client with hyperkalemia may exhibit peaked T waves on an electrocardiogram. This manifestation is an early sign of high potassium levels, but the diagnosis should not be based on this aspect alone. Untreated, hyperkalemia can lead to progressively worsening cardiac instability.
- A. A lumbar puncture takes a sample of cerebrospinal fluid from the back, which will be analyzed by the lab.
- B. The physician will insert a needle at the level of L4-L5 in the spinal cord.
- C. The client should lie flat on their back for a specific period following the procedure.
- D. The risks of the procedure include headache, back pain, and infection.
Correct Answer: B
Rationale: A lumbar puncture is performed to obtain cerebrospinal fluid for analysis to investigate various conditions affecting the client. During the procedure, the client is typically positioned on their side or sitting leaning over a table with their back rounded. The physician inserts a needle into the back around the L4-L5 vertebrae to collect the sample. Option A is incorrect because a lumbar puncture does not draw blood but instead collects cerebrospinal fluid. Option C is incorrect as the client should not necessarily lie flat for 24 hours post-procedure. Option D is incorrect as the common risks of a lumbar puncture include headache, back pain, and potential infection, not nausea, rash, or hypotension.
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A nurse is caring for a 3-day old infant who needs an exchange
transfusion. Which of the following statements is appropriate for
teaching the child's parents about this procedure?
- A. The registered nurse will be performing the procedure
- B. The procedure takes approximately 1 ? hours.
- C. The nurse will draw out 250cc of blood and then immediately replace
it with 250cc - D. The infant will continue to receive phototherapy during the
procedure.
Correct Answer: B
Rationale: : An exchange transfusion is a method of controlling high
bilirubin levels in infants when traditional phototherapy is
unsuccessful. During an exchange transfusion, the physician removes
5-10 cc of blood and then replaces it with donor blood. The parents of
this infant should know that the procedure is always performed by a
physician and will take approximately 1 ½ hours to complete.
Which of the following situations might warrant a laboratory magnesium level?
- A. Hyperthyroidism
- B. Arthritis
- C. Ulcerative colitis
- D. Depression
Correct Answer: C
Rationale: Ulcerative colitis can lead to symptoms such as abdominal pain, fever, diarrhea, and weight loss. This condition may impact the absorption of certain nutrients, including magnesium. Therefore, patients with chronic gastrointestinal conditions like ulcerative colitis should be screened for electrolyte imbalances related to impaired digestion. Hyperthyroidism, arthritis, and depression do not typically directly affect magnesium levels in the same way as gastrointestinal conditions like ulcerative colitis.
A client is preparing to give a stool sample for occult blood. All of the following information is part of teaching for this client EXCEPT:
- A. Avoid eating red meat for 3 days before the test
- B. Collect the stool sample from the toilet after having a bowel movement
- C. The stool does not need to be kept in a container with preservative
- D. A small part of the stool from two areas will be tested using a smear
Correct Answer: B
Rationale: When preparing to give a stool sample for occult blood testing, clients need specific instructions to ensure accurate results. It is crucial to educate clients to avoid eating red meat for at least 3 days before the test, as the blood in the meat can interfere with the test results. Clients should be informed that the stool does not need to be kept in a container with preservative as it is not required for this type of testing. Additionally, clients should be aware that a small part of the stool from two areas will be tested using a smear. However, collecting the stool sample from the toilet after having a bowel movement is not recommended as it may introduce contaminants and affect the accuracy of the test. Therefore, this information is not part of the correct teaching for the client preparing to give a stool sample for occult blood.
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.
A nurse is assisting a pregnant client who is having an amniocentesis.
Which of the following statements by the nurse indicates the correct
teaching for this procedure?
- A. I'm going to help you lie lat on your back for this."
- B. Don't worry, I'm sure everything will be all right."
- C. I will need to help you remove your shirt for this procedure."
- D. Now that the procedure is inished, I will put a small bandage over the puncture site."
Correct Answer: D
Rationale: An amniocentesis is performed to draw amniotic luid
from the sac around the fetus during pregnancy. It may be analyzed for
certain disorders or complications associated with pregnancy.
Following the procedure, the nurse should wash the client's abdomen
and place a small bandage over the puncture site