Nokea
The client is diagnosed with pancreatitis. Which laboratory value is most indicative of this condition?
- A. Elevated amylase
- B. Decreased bilirubin
- C. Elevated hemoglobin
- D. Decreased white blood cell count
Correct Answer: A
Rationale: Elevated amylase is a key indicator of pancreatitis, as it is released from damaged pancreatic tissue. Bilirubin, hemoglobin, and white blood cell counts are less specific, though leukocytosis may occur.
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A client with a history of heart failure is admitted with complaints of dyspnea. The nurse should give priority to:
- A. Administering diuretics
- B. Monitoring blood pressure
- C. Administering pain medication
- D. Monitoring temperature
Correct Answer: A
Rationale: Diuretics reduce fluid overload in heart failure, relieving dyspnea and improving oxygenation.
Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?
- A. Fresh fruit
- B. A milkshake
- C. Saltine crackers and peanut butter
- D. A ham and cheese sandwich
Correct Answer: B
Rationale: While fresh fruit is low in protein, a milkshake is a better choice as it provides carbohydrates and some protein in a form that is easier to digest, which is crucial for clients with cirrhosis to avoid ammonia buildup. A milkshake is appropriate as it provides carbohydrates, which are needed to prevent protein catabolism, and has lower protein content compared to options like peanut butter or ham, reducing the risk of ammonia accumulation. (C, D) Both saltine crackers with peanut butter and a ham and cheese sandwich are high in protein, which can increase ammonia levels, exacerbating hepatic encephalopathy.
A nurse is preparing to mix and administer chemotherapy. What equipment would be unnecessary to obtain?
- A. Surgical gloves
- B. Luer lok fitting IV tubing
- C. Surgical hat cover
- D. Disposable long-sleeve gown
Correct Answer: C
Rationale: Surgical gloves, Luer lok tubing, and long-sleeve gowns are essential for safe chemotherapy administration to prevent exposure. A surgical hat cover (C) is not typically required unless in a sterile procedure.
In planning daily care for a client with multiple sclerosis, the nurse would take into consideration that multiple sclerosis:
- A. Becomes progressively debilitating without remission
- B. Has unpredictable remissions and exacerbations
- C. Is rapidly fatal
- D. Responds quickly to antimicrobial therapy
Correct Answer: B
Rationale: Multiple sclerosis eventually becomes debilitating, but it is characterized by remission of symptoms. Remissions and exacerbations are unpredictable with multiple sclerosis. The client experiences progressive dysfunction after each exacerbation episode. Multiple sclerosis is usually slowly progressive. Multiple sclerosis is an autoimmune disease. Antimicrobial therapy has no effect on its course.
Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, 'Begin oxytocin induction at 1 mU/min.' The nurse should:
- A. Begin the oxytocin induction as ordered
- B. Increase the dosage by 2 mU/min increments at 15-minute intervals
- C. Maintain the dosage when duration of contractions is 40-60 seconds and frequency is at 2-1/2-4 minute intervals
- D. Question the order
Correct Answer: D
Rationale: Oxytocin stimulates labor but should not be used until CPD (cephalopelvic disproportion) is ruled out in a dysfunctional labor. This answer is the correct protocol for oxytocin administration, but the medication should not be used until CPD is ruled out. This answer is the correct manner to interpret effective stimulation, but oxytocin should not be used until CPD is ruled out. This answer is the appropriate nursing action because the scenario presents a dysfunctional labor pattern that may be caused by CPD. Oxytocin administration is contraindicated in CPD.