Clinitest is used in testing the urine of a client for glucose. Which of the following, if committed by a nurse, indicates an error?
- A. Specimen is collected after meals
- B. The nurse puts the clingiest tablet into a test tube
- C. She added 5 drops of urine and 10 drops of water
- D. If the color becomes orange or red, It is considered
Correct Answer: C
Rationale: When conducting a Clinitest for testing urinary glucose levels, it is essential to add the correct amounts of urine and Clinitest reagent as instructed. Adding more water than urine could dilute the sample, leading to inaccurate test results. It's important to follow the correct ratio of drops specified in the instructions for an accurate reading.
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A client who is postpartum and has been diagnosed with iron deficiency anemia is receiving education from a nurse. Which dietary recommendation should be included in the education plan?
- A. Yogurt and mozzarella
- B. Spinach and beef
- C. Fish and cottage cheese
- D. Turkey slices and milk
Correct Answer: B
Rationale: The correct answer is B: 'Spinach and beef.' Spinach and beef are high in iron, which is crucial for treating iron deficiency anemia. Spinach is a good source of non-heme iron, while beef provides heme iron, making them effective choices to increase iron levels in the body. Yogurt and mozzarella (Choice A), fish and cottage cheese (Choice C), and turkey slices and milk (Choice D) do not contain as high iron content as spinach and beef, making them less effective in addressing iron deficiency anemia.
What causes hepatic encephalopathy?
- A. Buildup of ammonia in the body
- B. Buildup of urea in the body
- C. Fatty infiltration of the liver
- D. Jaundice
Correct Answer: A
Rationale: Hepatic encephalopathy is caused by the buildup of ammonia in the body, not urea. Ammonia accumulates due to liver dysfunction, leading to neurological symptoms. Fatty infiltration of the liver may lead to conditions like non-alcoholic fatty liver disease, but it is not the direct cause of hepatic encephalopathy. Jaundice is a symptom of liver dysfunction but is not the primary cause of hepatic encephalopathy.
Warfarin (Coumadin) is an anticoagulant and interferes with the action of:
- A. Platelets
- B. Vitamin K
- C. Calcium
- D. Vitamin B12
Correct Answer: B
Rationale: The correct answer is B: Vitamin K. Warfarin works by inhibiting the action of vitamin K, which is crucial for the synthesis of clotting factors in the blood. By interfering with vitamin K, warfarin decreases the production of these clotting factors, thereby prolonging the time it takes for blood to clot. This is why individuals on warfarin therapy need to monitor their vitamin K intake. Choices A, C, and D are incorrect because warfarin does not directly interfere with platelets, calcium, or vitamin B12.
What causes hepatic encephalopathy?
- A. Buildup of ammonia in the body
- B. Buildup of urea in the body
- C. Fatty infiltration of the liver
- D. Jaundice
Correct Answer: A
Rationale: Hepatic encephalopathy is caused by the buildup of ammonia in the body. Ammonia, a byproduct of protein metabolism, normally gets converted to urea in the liver for excretion. However, in liver dysfunction, such as cirrhosis, the liver cannot effectively convert ammonia to urea, leading to its accumulation in the body and subsequently causing hepatic encephalopathy. Choices B, C, and D are incorrect as they do not directly relate to the pathophysiology of hepatic encephalopathy.
Which of the following statements does NOT apply to a nursing plan of care?
- A. It contains short-term goals
- B. It is developed by the patient's physician
- C. It must be continually evaluated
- D. It contains long-range goals
Correct Answer: B
Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate needs. Choice C is also accurate as nursing plans of care need to be continually evaluated and updated to ensure they are effective. Choice D is incorrect as nursing plans of care can contain long-range goals to provide a roadmap for the patient's overall care and recovery.