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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.
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A nurse is caring for a client who has asthma and is taking fluticasone. The nurse should monitor the client for which of the following adverse effects?
- A. Oral candidiasis
- B. Hypertension
- C. Increased appetite
- D. Weight loss
Correct Answer: A
Rationale: The correct answer is A: Oral candidiasis. Fluticasone is a corticosteroid inhaler commonly used to manage asthma. Corticosteroids can suppress the immune system locally, leading to oral candidiasis. The nurse should monitor for white patches in the mouth. Hypertension (B), increased appetite (C), and weight loss (D) are not commonly associated with fluticasone use.
A nurse is preparing a client who has AIDS for discharge. Which of the following statements should the nurse include in the discharge instructions?
- A. Prevent the spread of infection with good household cleaning practices.
- B. Limit handwashing to once a day to avoid skin damage.
- C. Avoid sharing towels with other people in the household.
- D. Do not disinfect surfaces in the home with bleach.
Correct Answer: A
Rationale: The correct answer is A: Prevent the spread of infection with good household cleaning practices. The nurse should include this statement in the discharge instructions because individuals with AIDS have weakened immune systems, making them more susceptible to infections. Good household cleaning practices can help prevent the spread of infections to the client and others.
Incorrect choices:
B: Limit handwashing to once a day to avoid skin damage - This is incorrect as frequent handwashing is crucial to prevent the spread of infections.
C: Avoid sharing towels with other people in the household - This is incorrect as sharing towels can lead to the transmission of infections.
D: Do not disinfect surfaces in the home with bleach - This is incorrect as disinfecting surfaces with bleach is important to kill harmful pathogens.
A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform?
- A. Tinel's sign
- B. Phalen's test
- C. Rinne's test
- D. Romberg test
Correct Answer: B
Rationale: The correct answer is B: Phalen's test. Phalen's test is used to assess for carpal tunnel syndrome by having the client flex the wrists and press the backs of the hands together for 1 minute to compress the median nerve. This test reproduces symptoms in individuals with carpal tunnel syndrome due to increased pressure on the median nerve. Tinel's sign (A) is used to assess for nerve compression, but it is not specific to carpal tunnel syndrome. Rinne's test (C) is used to assess for hearing loss. Romberg test (D) is used to assess for balance and proprioception issues. Choices E, F, and G are not relevant to assessing carpal tunnel syndrome.
A nurse assesses a client in skeletal traction. What indicates infection at the pin sites?
- A. Pallor
- B. Fever
- C. Bradycardia
- D. Elevated blood pressure
Correct Answer: B
Rationale: The correct answer is B: Fever. Infection at the pin sites in skeletal traction commonly presents with systemic signs like fever. Fever is a typical response to infection as the body tries to fight off the invading pathogens. Pallor, bradycardia, and elevated blood pressure are not specific indicators of infection at pin sites. Pallor may indicate poor perfusion, bradycardia is a slow heart rate which is not typically associated with infection, and elevated blood pressure can be a response to various stressors but not a specific sign of infection at pin sites. In summary, fever is the most reliable indicator of infection at pin sites due to its systemic nature.
A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?
- A. Avoid foods prepared with tap water.
- B. Use purified water for drinking.
- C. Limit intake of fried foods.
- D. Get vaccinated for hepatitis C.
Correct Answer: A
Rationale: The correct answer is A: Avoid foods prepared with tap water. Tap water in certain regions may be contaminated with hepatitis-causing viruses. Using bottled or purified water for drinking alone (choice B) may not prevent exposure through food preparation. Limiting fried foods (choice C) is unrelated to preventing viral hepatitis. While getting vaccinated for hepatitis C (choice D) is important, it is not directly related to preventing exposure through contaminated tap water. Therefore, the most effective preventive measure is to avoid foods prepared with tap water to reduce the risk of acquiring viral hepatitis.