Nokea
The client is admitted with a possible myocardial infarction. The nurse would anticipate an order from the physician for which laboratory test?
- A. Creatine kinase
- B. Ammonia
- C. Myoglobin
- D. Troponin T
- E. Gamma-glutamyl transferase
- F. Bilirubin
Correct Answer: A, C, D
Rationale: Creatine kinase (A), myoglobin (C), and troponin T (D) are cardiac biomarkers elevated in myocardial infarction. Ammonia (B), gamma-glutamyl transferase (E), and bilirubin (F) are unrelated to acute cardiac events.
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The client is admitted with a diagnosis of postpartum endometritis. Which symptom is most characteristic?
- A. Foul-smelling lochia
- B. Painless vaginal bleeding
- C. Fetal distress
- D. Maternal hypotension
Correct Answer: A
Rationale: Postpartum endometritis causes foul-smelling lochia due to uterine infection. Painless bleeding suggests other causes fetal distress is irrelevant postpartum and hypotension occurs only in severe cases.
A client with cancer is experiencing a common side effect of chemotherapy administration. Which laboratory assessment finding would cause the most concern?
- A. A sodium level of 50 mg/dL
- B. A blood glucose of 110 mg/dL
- C. A platelet count of 125,000/mm3
- D. A white cell count of 5,000/mm3
Correct Answer: A
Rationale: A sodium level of 50 mg/dL is impossible (likely a typo for 50 mEq/L, which is severely hyponatremic) and life-threatening, causing seizures. Glucose (B), platelets (C), and WBC (D) are near normal or less critical.
Why is Phytonadione (vitamin K) administered to a newborn shortly after birth?
- A. To stop hemorrhage
- B. To treat infection
- C. To replace electrolytes
- D. To facilitate clotting
Correct Answer: D
Rationale: Newborns have low vitamin K levels, necessary for clotting factor synthesis. Phytonadione is given to facilitate clotting and prevent hemorrhagic disease of the newborn. It does not stop active hemorrhage, treat infections, or replace electrolytes.
A client is placed on lithium therapy for her manic-depressive illness. When monitoring the client, the nurse assesses the laboratory blood values. Toxicity may occur with lithium therapy when the blood level is above:
- A. 1.0 mEq/L
- B. 2.2 mEq/L
- C. 0.03 mEq/L
- D. 1.5 mEq/L
Correct Answer: D
Rationale: This value is the level at which most clients are maintained, and toxicity may occur if the level increases. The client should be monitored closely for symptoms, because some clients become toxic even at this level.
A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility?
- A. Providing him with books, challenging puzzles, and games as diversionary activities
- B. Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision
- C. Having a volunteer come in to sit with the client and to read him stories
- D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client's position frequently
Correct Answer: B
Rationale: Self-care is usually well received by the child, and it is one of the most useful interventions to help the child cope with immobility, providing a sense of control.