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A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of the following values?
- A. Creatinine
- B. Bilirubin
- C. Amylase
- D. Albumin
Correct Answer: C
Rationale: The correct answer is C: Amylase. In acute pancreatitis, there is inflammation of the pancreas leading to leakage of pancreatic enzymes like amylase into the blood. Elevated amylase levels are a hallmark of acute pancreatitis. Creatinine (A) is related to kidney function, bilirubin (B) to liver function, and albumin (D) to protein status. In acute pancreatitis, the focus is on pancreatic enzymes like amylase.
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A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
- A. Inspect the mouth for signs of inhalation injuries
- B. Administer pain medication
- C. Place the client on oxygen therapy
- D. Start an intravenous line
Correct Answer: A
Rationale: The correct answer is A: Inspect the mouth for signs of inhalation injuries. This is the priority action because inhalation injuries can be life-threatening and must be assessed immediately in burn patients. Burns to the face and chest increase the risk of inhalation injuries due to the proximity to the airway. Administering pain medication, placing the client on oxygen therapy, and starting an IV line are important interventions but inspecting the mouth for signs of inhalation injuries takes precedence in this situation to ensure the client's airway is not compromised.
A client reports skin dryness, redness, and scaling after radiation. What should the nurse advise?
- A. Apply hydrating lotions.
- B. Scrub the area vigorously.
- C. Cover the area with adhesive bandages.
- D. Avoid moisturizing the skin.
Correct Answer: A
Rationale: The correct answer is A: Apply hydrating lotions. After radiation, skin can become dry and irritated. Hydrating lotions help to moisturize the skin and reduce dryness, redness, and scaling. They provide a protective barrier and promote skin healing. Advising the client to apply hydrating lotions is essential in maintaining skin integrity post-radiation.
Choice B: Scrubbing the area vigorously can further damage the skin and exacerbate irritation.
Choice C: Covering the area with adhesive bandages can trap moisture and lead to skin maceration.
Choice D: Avoiding moisturizing the skin can worsen dryness and discomfort.
A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?
- A. C-reactive protein
- B. Erythrocyte sedimentation rate (ESR)
- C. White blood cell count
- D. Hematocrit
Correct Answer: B
Rationale: The correct answer is B: Erythrocyte sedimentation rate (ESR). ESR is a common test used to monitor inflammation levels in rheumatoid arthritis (RA) patients. Aspirin is an anti-inflammatory medication, so monitoring ESR can help assess the effectiveness of the treatment. A decrease in ESR levels indicates a reduction in inflammation, suggesting that the aspirin is working. The other choices (A, C, D) are not specific to monitoring the effectiveness of aspirin in RA. C-reactive protein and white blood cell count are general markers of inflammation and infection, not specific to RA. Hematocrit measures red blood cell levels, which are not directly related to the effectiveness of aspirin in treating RA.
A nurse is reviewing the laboratory values of a client who had a myocardial infarction 3 hr ago. The nurse should expect which of the following laboratory values to be elevated?
- A. Serum sodium
- B. Serum glucose
- C. Troponin I
- D. White blood cell count
Correct Answer: C
Rationale: The correct answer is C: Troponin I. Troponin I is a specific marker for myocardial damage. After a myocardial infarction, the damaged heart muscle releases troponin I into the bloodstream, leading to elevated levels. This helps in diagnosing and monitoring the extent of myocardial damage.
A: Serum sodium levels are not typically affected by a myocardial infarction.
B: Serum glucose levels may be elevated due to stress response but are not specific to myocardial infarction.
D: White blood cell count may be elevated in response to inflammation caused by myocardial infarction, but it is not as specific as troponin I.
A nurse is teaching a client with Addison's disease about its cause. What should the nurse say?
- A. It is caused by the overproduction of growth hormone.
- B. It is caused by the lack of production of aldosterone by the adrenal gland.
- C. It is caused by excess thyroid hormone.
- D. It is caused by overactive adrenal glands.
Correct Answer: B
Rationale: The correct answer is B: Addison's disease is caused by the lack of production of aldosterone by the adrenal gland. Aldosterone is a hormone produced by the adrenal glands that helps regulate blood pressure and electrolyte balance in the body. In Addison's disease, the adrenal glands do not produce enough aldosterone, leading to symptoms like low blood pressure, weakness, and electrolyte imbalances. Choice A is incorrect because Addison's disease is not caused by the overproduction of growth hormone. Choice C is incorrect as it mentions excess thyroid hormone, which is not related to Addison's disease. Choice D is incorrect because Addison's disease is characterized by underactive, not overactive, adrenal glands.