Nokea
A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidyl glycerol is noted. The nurse's assessment of this data is:
- A. The infant is at low risk for congenital anomalies.
- B. The infant is at high risk for intrauterine growth retardation.
- C. The infant is at high risk for respiratory distress syndrome.
- D. The infant is at high risk for birth trauma.
Correct Answer: C
Rationale: An L/S ratio of 1:1 and presence of phosphatidyl glycerol suggest immature lungs, indicating a high risk for respiratory distress syndrome, so C is correct. Answers A, B, and D are not directly related to these findings.
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Vital signs
Temperature 95 F (35 C)
Blood pressure 90/50 mm Hg
Heart rate 50/min
Respirations 6/min
SpO2 83%
The nurse is caring for a client with hypothyroidism who has become lethargic and difficult to rouse. Which action is the priority?
- A. Administer scheduled PO levothyroxine
- B. Perform bag-valve-mask ventilation
- C. Place a warming blanket on the client
- D. Review client's thyroid laboratory results
Correct Answer: B
Rationale: Lethargy and unresponsiveness in hypothyroidism suggest myxedema coma, requiring immediate airway management with ventilation (B). Levothyroxine (A), warming (C), and lab review (D) are secondary.
Laboratory reference ranges
INR (Therapeutic – atrial fibrillation)
2.0-3.0
The nurse has reinforced teaching for a client with atrial fibrillation who is receiving warfarin. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. Antibiotics can affect my INR value.'
- B. I am going to eat more leafy green vegetables.'
- C. I will take the medication at the same time every day.'
- D. I understand that my INR value should be between 4 and 5.'
- E. If I miss a dose of medication, I'll double my dose the next day.'
Correct Answer: A, C
Rationale: Antibiotics affecting INR (A) and consistent timing (C) are correct. More leafy greens (B) can lower INR, INR of 4-5 (D) is too high, and doubling doses (E) is dangerous.
The client with hyperparathyroidism will exhibit signs of:
- A. Hypokalemia
- B. Hyponatremia
- C. Hypercalcemia
- D. Hyperphosphatemia
Correct Answer: C
Rationale: Hyperparathyroidism increases parathyroid hormone, causing hypercalcemia by mobilizing calcium from bones and increasing absorption. Hypokalemia , hyponatremia , and hyperphosphatemia are not typically associated.
A very tall, heavy-set man is admitted. The nurse is taking vital signs. Which statement is correct concerning taking the blood pressure?
- A. 10 mm should be added to each reading to compensate for the cuff size.
- B. 15 mm should be subtracted from the systolic reading, and 10 mm should be subtracted from the diastolic reading.
- C. An extra-large cuff is needed to obtain an accurate measurement.
- D. The client should lie down before the blood pressure is taken.
Correct Answer: C
Rationale: An extra-large cuff ensures accurate blood pressure measurement in large individuals; a standard cuff falsely elevates readings. Adjusting readings or lying down is unnecessary.
A client is admitted with Parkinson's disease. The client has been taking Carbidopa/levodopa (Sinemet) for 1 year. Which clinical manifestation would be the most important to report?
- A. Dry mouth
- B. Spasmodic eye winking
- C. Dark urine
- D. Dizziness
Correct Answer: B
Rationale: Spasmodic eye winking could indicate a toxicity or overdose and should be reported to the physician. Other signs of toxicity include involuntary twitching of muscles, facial grimaces, and severe tongue protrusion. Answers A, C, and D are incorrect because they are side effects of the drug.