Nokea
The client is admitted with a diagnosis of gestational hypertension. Which vital sign change is most concerning?
- A. Blood pressure of 160/110
- B. Heart rate of 90 bpm
- C. Respiratory rate of 20 breaths per minute
- D. Temperature of 98.6°F
Correct Answer: A
Rationale: A blood pressure of 160/110 indicates severe gestational hypertension increasing the risk of complications like stroke or eclampsia and requires immediate intervention. The other vital signs are normal.
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A client receiving Vancocin (vancomycin) has a serum level of 20 mcg/mL. The nurse knows that the therapeutic range for vancomycin is:
- A. 5-10 mcg/mL
- B. 10-25 mcg/mL
- C. 25-40 mcg/mL
- D. 40-60 mcg/mL
Correct Answer: B
Rationale: The therapeutic range for vancomycin is 10-25 mcg/mL, ensuring effective treatment of infections while minimizing toxicity risks.
Which client should be assigned to the nursing assistant?
- A. The 18-year-old with a fracture to two cervical vertebrae
- B. The infant with meningitis with a temperature of 101°F
- C. The elderly client with a thyroidectomy four days ago
- D. The client with a thoracotomy two days ago
Correct Answer: C
Rationale: The elderly client four days post-thyroidectomy is stable and suitable for a nursing assistant’s care (e.g., basic hygiene, ambulation). The other clients require skilled nursing due to critical conditions (cervical fracture, meningitis, recent thoracotomy).
The nurse is caring for a client following a myocardial infarction. Which of the following enzymes are specific to cardiac damage?
- A. SGOT and LDH
- B. SGOT and CK BB
- C. LDH and CK MB
- D. LDH and CK BB
Correct Answer: C
Rationale: CK-MB and LDH are specific to cardiac damage, with CK-MB being highly specific for myocardial infarction due to its presence in heart muscle.
An obstetrical client with diabetes has an amniocentesis at 28 weeks gestation. Which test indicates the degree of fetal lung maturity?
- A. Alpha-fetoprotein
- B. Estriol level
- C. Indirect Coombs
- D. Lecithin sphingomyelin ratio
Correct Answer: D
Rationale: The lecithin-sphingomyelin (L/S) ratio measures fetal lung maturity by assessing surfactant production, critical for preventing respiratory distress syndrome in preterm infants.
The nurse is caring for a client after a motor vehicle accident. The client has a fractured tibia, and bone is noted protruding through the skin. Which action is of priority?
- A. Provide manual traction above and below the leg.
- B. Cover the bone area with a sterile dressing.
- C. Apply an ACE bandage around the entire lower limb.
- D. Place the client in the prone position.
Correct Answer: B
Rationale: Covering an open fracture with a sterile dressing prevents infection, a priority. Traction (A) is secondary, an ACE bandage (C) may contaminate the wound, and prone positioning (D) is inappropriate.