Nokea
The client diagnosed with tonsillitis is scheduled to have surgery in the morning. Which assessment data should the nurse notify the health-care provider about prior to surgery?
- A. The client has a hemoglobin of 12.2 g/dL and hematocrit of 36.5%.
- B. The client has an oral temperature of 100.2°F and a dry cough.
- C. There are one (1) to two (2) white blood cells (WBCs) in the urinalysis.
- D. The client's current international normalized ratio (INR) is 1.
Correct Answer: B
Rationale: Fever (100.2°F) and cough (B) suggest infection, a surgical risk requiring HCP notification. Hb/Hct (A) are near normal, WBCs in urine (C) are insignificant, and INR 1 (D) is normal.
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A patient's D-dimer result is <500 ng/mL (FEU). The nurse knows that the D-dimer assesses and this result means?
- A. fibrin degradation fragment; positive for a blood clot
- B. platelet degradation protein; negative for a blood clot
- C. clotting factors; positive for a blood clot
- D. fibrin degradation fragment; negative for a blood clot
Correct Answer: D
Rationale: A d-dimer test assess fibrin degradation fragment. This test doesn't tell us where the clot may be (so it not specific) so it will need to be further investigated by the MD and a positive result doesn't necessarily mean the patient has a clot because some disease processes can cause a false positive. Also, a normal d-dimer is <500 ng/mL (FEU). However, it depends on how the lab reports the assay cut-off value for the d-dimer. Some labs have a cutoff <250 ng/mL (D-DU). However, <500 ng/mL (FEU) is equivalent to <250 ng/mL (D-DU).
During the preoperative period, which nursing action will be of greatest priority for a person who is to have a laryngectomy?
- A. Establish a means of communication.
- B. Prepare the bowel by administering enemas until clear.
- C. Teach the client to use an artificial larynx.
- D. Demonstrate the technique for suctioning a laryngectomy tube.
Correct Answer: A
Rationale: Establishing a means of communication is the highest priority preoperatively, as the client will lose the ability to speak post-laryngectomy.
A patient with active tuberculosis is taking Ethambutol. As the nurse you make it priority to assess the patient's?
- A. hearing
- B. mental status
- C. vitamin B6 level
- D. vision
Correct Answer: D
Rationale: Ethambutol can cause optic neuritis, leading to vision changes. The nurse must prioritize assessing the patient's vision to detect this side effect early.
Which intervention should the emergency department nurse implement first for the client admitted for an acute asthma attack?
- A. Administer glucocorticoids intravenously.
- B. Administer oxygen 5 L per nasal cannula.
- C. Establish and maintain a 20-gauge saline lock.
- D. Assess breath sounds every 15 minutes.
Correct Answer: B
Rationale: In an acute asthma attack, the priority is to address hypoxia. Administering oxygen (B) ensures adequate oxygenation, which is critical in respiratory distress. IV glucocorticoids (A) reduce inflammation but act slowly and are not the first intervention. Establishing a saline lock (C) is preparatory but not immediate. Assessing breath sounds (D) is important but secondary to ensuring oxygenation.
The nurse is taking the social history from a client diagnosed with small cell carcinoma of the lung. Which information is significant for this disease?
- A. The client worked with asbestos for a short time many years ago.
- B. The client has no family history for this type of lung cancer.
- C. The client has numerous tattoos covering both upper and lower arms.
- D. The client has smoked two (2) packs of cigarettes a day for 20 years.
Correct Answer: D
Rationale: Smoking (D) (40 pack-years) is the primary risk factor for small cell lung cancer. Asbestos (A) is a risk but less significant, family history (B) is irrelevant, and tattoos (C) are unrelated.