Nokea
A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?
- A. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels
- B. Low levels of urine constituents normally excreted in the urine
- C. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
- D. Electrolyte imbalance that could affect the blood’s ability to coagulate properly
Correct Answer: C
Rationale: Rationale for Correct Answer (C): A complete blood count (CBC) is used to identify abnormalities in red blood cells, white blood cells, and platelets. Hematocrit (HCT) and hemoglobin (Hb) levels are part of a CBC and indicate the oxygen-carrying capacity of the blood. Abnormally low HCT and Hb levels can signify conditions like anemia, which can impact a client's ability to undergo surgery due to potential complications related to oxygen delivery.
Summary of Incorrect Choices:
A: Potential hepatic dysfunction is not directly related to a CBC, and BUN/creatinine levels are markers for kidney function, not liver function.
B: Low levels of urine constituents are not assessed in a CBC, which focuses on blood components.
D: Electrolyte imbalance is not specifically tested in a CBC; it is usually evaluated through separate blood tests. Coagulation factors are not directly measured in a CBC.
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The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
- A. Completes a comprehensive database
- B. Identifies pertinent nursing diagnoses
- C. Intervenes based on priorities of patient care
- D. Determines whether outcomes have been achieved
Correct Answer: A
Rationale: The correct answer is A: Completes a comprehensive database. During the first phase of the nursing process (assessment), the nurse collects data to establish a comprehensive database of the patient's health status. This information serves as the foundation for identifying nursing diagnoses, planning interventions, and evaluating outcomes. Identifying nursing diagnoses (B) occurs in the second phase (diagnosis), intervening based on priorities (C) in the third phase (planning), and determining outcomes achieved (D) in the fourth phase (evaluation). Completing a comprehensive database is crucial in the initial assessment phase to gather accurate information for the subsequent steps in the nursing process.
A patient is admitted to a medical unit with a diagnosis of heart failure. The patient reports that she has had increasing fatigue during the past 2 weeks. Which of the following is the most likely cause of this fatigue?
- A. Dyspnea
- B. Decreased cardiac output
- C. Dry cough
- D. Orthopnea
Correct Answer: B
Rationale: The correct answer is B: Decreased cardiac output. Fatigue in heart failure is primarily due to decreased cardiac output, leading to reduced oxygen and nutrient delivery to tissues, causing fatigue. Dyspnea (A) is shortness of breath, not fatigue. Dry cough (C) is more associated with conditions like pulmonary issues, not fatigue. Orthopnea (D) is difficulty breathing while lying down, not specifically related to fatigue. Hence, decreased cardiac output is the most likely cause of fatigue in this patient.
As the nurse cares for a patient with angioedema, differs from urticaria in that angioedema is characterized by which of the following?
- A. Angioedema is more pruritic.
- B. Angioedema has small, fluid-filled vesicles
- C. Angioedema has a deeper and more that crust.
- D. Angioedema lasts a shorter time.
Correct Answer: C
Rationale: Step-by-step rationale for choice C: Angioedema differs from urticaria as it involves deeper swelling in the dermis and subcutaneous tissue, leading to a more profound and firm texture. This contrasts with urticaria, which presents as superficial, raised wheals on the skin. Therefore, option C is correct.
Summary of other choices:
A: Angioedema is not typically associated with intense itching, so it is not more pruritic than urticaria.
B: Angioedema does not have small, fluid-filled vesicles like in allergic contact dermatitis.
D: Angioedema tends to last longer than urticaria, making this statement incorrect.
The activation of B cells in humoral immunity is assisted by which of the following?
- A. Cytotoxic T cells
- B. Suppressor T cells
- C. Helper T cells
- D. Neutrophils
Correct Answer: C
Rationale: The correct answer is C: Helper T cells. Helper T cells play a crucial role in activating B cells by releasing cytokines that stimulate B cell proliferation and differentiation. They also help in the production of antibodies. Cytotoxic T cells (A) are involved in cell-mediated immunity, not humoral immunity. Suppressor T cells (B) regulate the immune response and do not directly assist in B cell activation. Neutrophils (D) are phagocytic cells involved in innate immunity, not in activating B cells in humoral immunity.
The nurse is caring for a patient with HIV who has diarrhea. Which of the following would be most therapeutic to teach the patient to avoid in the diet to reduce diarrhea?
- A. Potassium-rich food
- B. Liquid nutritional supplements
- C. Raw fruits and vegetables
- D. Frozen products
Correct Answer: C
Rationale: The correct answer is C: Raw fruits and vegetables. Patients with HIV and diarrhea should avoid raw fruits and vegetables due to their high fiber content, which can exacerbate diarrhea symptoms. Fiber can increase bowel movements and worsen diarrhea. Therefore, avoiding raw fruits and vegetables can help reduce diarrhea.
Choice A (Potassium-rich food) is not the best answer because potassium-rich foods are important for patients with HIV to maintain electrolyte balance. Choice B (Liquid nutritional supplements) can actually be beneficial in providing essential nutrients to patients with HIV. Choice D (Frozen products) is not directly related to diarrhea management in patients with HIV.