Nokea
A nurse is teaching a newly licensed nurse about the purpose of a CA 125 test. Which of the following statements should the nurse include in the teaching?
- A. A CA 125 test is used to monitor a client's progress during treatment of ovarian cancer.
- B. A CA 125 test is used to detect pregnancy.
- C. A CA 125 test is used to diagnose cervical cancer.
- D. A CA 125 test is used to screen for prostate cancer.
Correct Answer: A
Rationale: The correct answer is A: A CA 125 test is used to monitor a client's progress during treatment of ovarian cancer. This is because CA 125 is a biomarker that is commonly elevated in ovarian cancer patients. Monitoring CA 125 levels helps healthcare providers assess the effectiveness of treatment and detect any recurrence of the disease.
Choice B is incorrect because a CA 125 test is not used to detect pregnancy. Choice C is incorrect because a CA 125 test is not used to diagnose cervical cancer; it is primarily associated with ovarian cancer. Choice D is incorrect because a CA 125 test is not used to screen for prostate cancer; it is specific to ovarian cancer.
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A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?
- A. Flat T wave
- B. Prominent U wave
- C. ST elevation
- D. Wide QRS complex
Correct Answer: B
Rationale: The correct answer is B: Prominent U wave. Hypokalemia, or low potassium levels, can cause the U wave to become more prominent on an EKG strip. This is due to delayed repolarization of the ventricles. A flat T wave (choice A) is typically associated with ischemia or infarction. ST elevation (choice C) is often seen in conditions like myocardial infarction. A wide QRS complex (choice D) is indicative of conduction abnormalities. Choices E, F, and G are not relevant to the interpretation of hypokalemia on an EKG strip.
A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects?
- A. Bleeding from the gums
- B. Chest pain
- C. Fatigue
- D. Severe headache
Correct Answer: A
Rationale: The correct answer is A: Bleeding from the gums. Myelosuppression leads to decreased production of blood cells, including platelets, which are essential for clotting. Bleeding from the gums is a common sign of thrombocytopenia, a condition where there are low platelet levels. Chest pain, fatigue, and severe headache are not directly associated with myelosuppression. Monitoring for bleeding tendencies is crucial in clients with myelosuppression to prevent complications like hemorrhage.
A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention?
- A. Clear breath sounds on the affected side
- B. Reduction in drainage output
- C. Development of subcutaneous emphysema
- D. Minimal pain at the surgical site
Correct Answer: C
Rationale: Subcutaneous emphysema, where air gets trapped under the skin, may indicate an underlying pneumothorax and should be reported to the provider.
A nurse is caring for a client who the provider suspects might have pernicious anemia. The nurse should expect the provider to prescribe which of the following diagnostic tests?
- A. Schilling test
- B. Complete blood count (CBC)
- C. Vitamin B12 level
- D. Bone marrow biopsy
Correct Answer: A
Rationale: The correct answer is A: Schilling test. Pernicious anemia is caused by vitamin B12 deficiency, often due to poor absorption. The Schilling test is specifically used to diagnose pernicious anemia by evaluating the body's ability to absorb vitamin B12. The test involves giving the patient a small amount of radioactive vitamin B12 to determine how well it is absorbed and utilized by the body. This test helps to differentiate pernicious anemia from other causes of B12 deficiency.
Choice B (Complete blood count) is a general test that may show abnormalities in red blood cells seen in anemia, but it does not specifically diagnose pernicious anemia. Choice C (Vitamin B12 level) alone may not differentiate between pernicious anemia and other causes of B12 deficiency. Choice D (Bone marrow biopsy) is not typically necessary for diagnosing pernicious anemia and is more invasive compared to the Schilling test.
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.