Nokea
A nurse cares for a client who is prescribed a serum catecholamine test. Which action should the nurse take?
- A. Discard the first sample and then begin the collection.
- B. Draw the blood sample after the client eats breakfast.
- C. Place the sample on ice and send to the laboratory immediately.
- D. Add preservatives before sending the sample to the laboratory.
Correct Answer: C
Rationale: Serum catecholamine samples must be placed on ice and sent to the laboratory immediately to maintain sample integrity and ensure accurate results.
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A nurse assesses a client who is prescribed a medication that stimulates beta1 receptors. Which assessment finding should alert the nurse to urgently contact the health care provider?
- A. Heart rate of 50 beats/min
- B. Respiratory rate of 18 breaths/min
- C. Oxygen saturation of 92%
- D. Blood pressure of 144/69 mm Hg
Correct Answer: A
Rationale: Stimulation of beta1 receptor sites in the heart has positive chronotropic and inotropic actions, leading to an increased heart rate and cardiac output. A heart rate of 50 beats/min indicates the client is not responding to the medication, which is a cause for concern.
A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is prescribed a 24-hour urine specimen collection. Which statement should the nurse include when delegating this activity to the UAP?
- A. Void the clients first void and collect urine for 24 hours.
- B. Add the preservative to the container at the end of the test.
- C. Start the collection by saving the first urine of the morning.
- D. Ensure the client drinks plenty of water during collection.
Correct Answer: A
Rationale: The 24-hour urine collection begins after discarding the first void to ensure a full 24-hour period of collection. This ensures accurate measurement of excreted substances.
A nurse assesses a female client who presents with hirsutism. Which question should the nurse ask when assessing this client?
- A. How do you plan to pay for your treatments?
- B. How do you feel about yourself?
- C. What medications are you prescribed?
- D. What are you doing to prevent this from happening?
Correct Answer: B
Rationale: Hirsutism, or excessive hair growth, can result from endocrine disorders and may cause a disruption in body image, especially for female clients. Asking about self-perception addresses the psychosocial impact of the condition.
A nurse evaluates laboratory results for a male client who reports fluid secretion from his breasts. Which hormone value should the nurse assess first?
- A. Posterior pituitary hormones
- B. Adrenal medulla hormones
- C. Anterior pituitary hormones
- D. Parathyroid hormone
Correct Answer: C
Rationale: Breast fluid secretion in males is often due to elevated prolactin levels, which is secreted by the anterior pituitary gland. Assessing anterior pituitary hormones is the priority.
A nurse prepares to palpate a clients thyroid gland. Which action should the nurse take when performing this assessment?
- A. Stand in front of the client instead of behind the client.
- B. Ask the client to swallow after palpating the thyroid.
- C. Palpate the right lobe with the nurses left hand.
- D. Place the client in a sitting position with the chin tucked down.
Correct Answer: D
Rationale: The correct technique for thyroid palpation involves the nurse standing behind the client, with the client in a sitting position and chin tucked down to relax the neck muscles, facilitating palpation of the thyroid gland.