Nokea
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 is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?
- A. Performing the procedure independently
- B. Preparing the suction equipment but needing assistance
- C. Demonstrating knowledge of the tracheostomy care instructions
- D. Asking for assistance with the suctioning procedure
Correct Answer: A
Rationale: The correct answer is A. Performing the procedure independently indicates readiness for discharge as it shows the partner has mastered the skill and can provide proper care without supervision. Choice B indicates the partner still needs assistance, choice C shows knowledge but not necessarily competency, and choice D suggests continued reliance on the nurse.
A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care?
- A. Fresh flowers and potted plants in the room
- B. Visitors from outside the hospital
- C. Foods high in vitamin C
- D. A humidifier in the room
Correct Answer: A
Rationale: The correct answer is A: Fresh flowers and potted plants in the room. Neutropenic clients are at high risk for infections due to low white blood cell count. Fresh flowers and potted plants can harbor bacteria and fungi, increasing the risk of infection. Restricting these items helps minimize exposure to pathogens. Choices B and D are incorrect as long as visitors are screened for infections and the humidifier is cleaned regularly. Choice C, foods high in vitamin C, is incorrect as these foods can actually help boost the immune system.
A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?
- A. Defibrillation
- B. Administer oxygen
- C. Call for help
- D. Start chest compressions
Correct Answer: A
Rationale: The correct answer is A: Defibrillation. Ventricular fibrillation is a life-threatening arrhythmia that requires immediate defibrillation to restore the heart's normal rhythm. Defibrillation is the priority as it is the most effective intervention to treat ventricular fibrillation and increase the chance of survival. Administering oxygen (B) is important but not the priority over defibrillation. Calling for help (C) should be done after initiating defibrillation. Starting chest compressions (D) should only be done if defibrillation is not immediately available or unsuccessful.
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.
A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care?
- A. Fresh flowers and potted plants in the room
- B. Use of public transportation
- C. Group activities
- D. Unrestricted visitors
Correct Answer: A
Rationale: The correct answer is A: Fresh flowers and potted plants in the room. Neutropenic clients are at high risk for infections due to low white blood cell count. Fresh flowers and plants can harbor bacteria and fungi that can potentially cause infections. Therefore, restricting fresh flowers and plants helps minimize the risk of infection. Choices B, C, and D are incorrect because they do not directly relate to the risk of infection in neutropenic clients. Using public transportation, engaging in group activities, or having visitors are generally safe as long as proper infection control measures are followed.