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A client's healthcare provider has ordered a 'liver panel' in response to the client's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select one that doesn't apply.
- A. Alanine aminotransferase (ALT)
- B. C-reactive protein (CRP)
- C. Gamma-glutamyl transferase (GGT)
- D. Aspartate aminotransferase (AST)
Correct Answer: B
Rationale: The correct answer is B: C-reactive protein (CRP). A liver panel typically includes tests such as ALT, GGT, and AST to assess liver function, but CRP is not part of a standard liver panel. CRP is a marker of inflammation and infection, not specific to liver function. Therefore, when reviewing the results of a liver panel for a client with jaundice, the nurse should not expect to see CRP among the blood tests.
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A 60-year-old man presents with fatigue, polyuria, and polydipsia. Laboratory tests reveal hyperglycemia and ketonuria. What is the most likely diagnosis?
- A. Type 1 diabetes mellitus
- B. Type 2 diabetes mellitus
- C. Diabetes insipidus
- D. Hyperthyroidism
Correct Answer: A
Rationale: The most likely diagnosis for a 60-year-old man with fatigue, polyuria, polydipsia, hyperglycemia, and ketonuria is Type 1 diabetes mellitus. The key clues are the presence of ketonuria, which indicates the body is breaking down fats for energy due to lack of insulin in Type 1 diabetes. Additionally, the acute onset of symptoms in an older individual suggests an autoimmune destruction of pancreatic beta cells seen in Type 1 diabetes. Type 2 diabetes is less likely due to the acute presentation and ketonuria. Diabetes insipidus presents with polyuria but not hyperglycemia or ketonuria. Hyperthyroidism typically presents with symptoms such as weight loss, tremors, and heat intolerance, not the classic symptoms seen in this case.
A client with liver cirrhosis and ascites is being treated with spironolactone. What is a key nursing consideration for this medication?
- A. Monitoring for signs of hyperkalemia
- B. Checking for signs of hypoglycemia
- C. Assessing for signs of dehydration
- D. Observing for symptoms of hyponatremia
Correct Answer: A
Rationale: The correct answer is A: Monitoring for signs of hyperkalemia. Spironolactone is a potassium-sparing diuretic commonly used in clients with liver cirrhosis and ascites. The key nursing consideration is monitoring potassium levels due to the risk of hyperkalemia, as spironolactone reduces potassium excretion. Hyperkalemia can lead to serious cardiac arrhythmias. Checking for hypoglycemia (B) is not directly related to spironolactone use. Assessing for dehydration (C) is important but not the key consideration for this medication. Observing for hyponatremia (D) is not a common side effect of spironolactone.
A client returns to the unit after a neck dissection. The surgeon placed a Jackson-Pratt drain in the wound. When assessing the wound drainage over the first 24 postoperative hours, what finding would prompt the nurse to notify the health care provider immediately?
- A. Presence of small blood clots in the drainage
- B. 60 mL of milky or cloudy drainage
- C. Spots of drainage on the dressings surrounding the drain
- D. 120 mL of serosanguinous drainage
Correct Answer: B
Rationale: The correct answer is B: 60 mL of milky or cloudy drainage. This finding could indicate the presence of an infection, which is a serious complication post-neck dissection. Milky or cloudy drainage may contain pus, indicating the need for immediate intervention to prevent further complications.
A: Presence of small blood clots in the drainage is relatively common and may not necessarily indicate a problem unless there are large clots or excessive bleeding.
C: Spots of drainage on the dressings surrounding the drain are expected and do not necessarily warrant immediate notification unless there is excessive leakage.
D: 120 mL of serosanguinous drainage is within the expected range for the first 24 hours postoperatively and may not be a cause for immediate concern unless there are other symptoms present.
A client with newly diagnosed type 2 diabetes is preparing for discharge. Which statement by the client indicates a need for further teaching?
- A. I will take my insulin shots only when my blood sugar is high
- B. I need to follow a balanced diet and exercise regularly
- C. I should monitor my blood sugar levels regularly
- D. I need to take my medication as prescribed by my doctor
Correct Answer: A
Rationale: The correct answer is A because insulin shots are not only taken when blood sugar is high in type 2 diabetes. Insulin therapy may be prescribed by the doctor to be taken at specific times regardless of blood sugar levels to manage the condition effectively. Choice B is correct as it emphasizes the importance of lifestyle modifications in managing diabetes. Choice C is correct as monitoring blood sugar levels is crucial for managing diabetes. Choice D is correct as adherence to prescribed medication is essential in controlling blood sugar levels.
A client with rheumatoid arthritis is prescribed methotrexate. Which instruction should the nurse include in the client's teaching?
- A. Avoid alcohol while taking this medication.
- B. Take the medication with a full meal.
- C. Increase your intake of high-fiber foods.
- D. Avoid exposure to sunlight.
Correct Answer: A
Rationale: The correct answer is A: Avoid alcohol while taking this medication. Methotrexate can cause liver toxicity, and alcohol consumption can exacerbate this risk. It is important for the client to avoid alcohol to prevent potential harm to the liver.
B: Taking the medication with a full meal is not a necessary instruction for methotrexate. It is typically recommended to take methotrexate on an empty stomach.
C: Increasing intake of high-fiber foods is not directly related to methotrexate therapy. It is important for overall health but not specifically for this medication.
D: Avoiding exposure to sunlight is not a common instruction for methotrexate. While some medications can increase sensitivity to sunlight, this is not a typical concern with methotrexate.