Nokea
The client with trigeminal neuralgia tells the nurse that acetaminophen (Tylenol) is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication?
- A. Sodium level of 140 mEq/l.
- B. Direct bilirubin level of 2 mg/dl
- C. Prothrombin time of 12 seconds
- D. Platelet count of 400,000/mm3
Correct Answer: B
Rationale: Acetaminophen toxicity can lead to hepatic injury, resulting in elevated liver enzymes, including bilirubin levels. Direct bilirubin is a specific marker for liver function and is typically elevated in cases of acetaminophen overdose or toxicity. Therefore, a direct bilirubin level of 2 mg/dl would indicate toxicity associated with acetaminophen use. Monitoring liver function tests, including bilirubin levels, is crucial when using acetaminophen long-term to prevent toxicity and liver damage.
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Which is an important nursing action related to the use of tape and/or adhesives on preterm newborns?
- A. Avoid using tape and adhesives until skin is more mature.
- B. Use solvents to remove tape and adhesives instead of pulling on skin.
- C. Remove adhesives with warm water or mineral oil.
- D. Use scissors carefully to remove tape instead of pulling tape off.
Correct Answer: A
Rationale: An important nursing action related to the use of tape and/or adhesives on preterm newborns is to avoid using tape and adhesives until the skin is more mature. Preterm newborns have delicate and fragile skin that is more prone to damage and injury. Using tape and adhesives on immature skin can increase the risk of skin tears, irritations, and damage. It is recommended to wait until the skin matures and becomes less delicate before using tape or adhesives on preterm newborns to prevent skin-related complications.
When evaluating a severely depressed adolescent, the nurse knows that one indicator of a high risk for suicide is:
- A. Depression
- B. Excessive sleepiness
- C. A history of cocaine use
- D. A preoccupation with death
Correct Answer: D
Rationale: A key indicator of high risk for suicide in a severely depressed adolescent is a preoccupation with death. This preoccupation may manifest as talking about death frequently, expressing a desire to die, or showing an interest in activities or media related to death. It is important for healthcare providers to take any mention of suicidal thoughts or intentions seriously and to assess for other risk factors. While depression, excessive sleepiness, and a history of cocaine use may also be concerning in an adolescent's mental health assessment, a preoccupation with death is a more direct indicator of suicidal risk. It is crucial for healthcare providers to address suicidal ideation promptly and to ensure the adolescent receives appropriate mental health support and interventions.
A woman with pelvic inflammatory disease complains of lower abdominal pain. Which action should the nurse take first?
- A. Have her rate her pain on a 0 to 10 scale
- B. Administer antibiotics as ordered
- C. Administer an analgesic as ordered
- D. Teach the patient about causes and prevention of STDs
Correct Answer: B
Rationale: The first priority when a woman with pelvic inflammatory disease complains of lower abdominal pain is to administer antibiotics as ordered. Pelvic inflammatory disease is often caused by a bacterial infection, and prompt treatment with antibiotics is crucial to prevent complications such as infertility or chronic pelvic pain. Addressing the infection promptly is essential in managing the condition and preventing further spread of the infection. Once antibiotic therapy has been initiated, the nurse can proceed with other interventions such as pain management (C), patient education on STDs (D), and assessing pain level (A).
Which of the following IV solutions is hypertonic?
- A. Normal saline
- B. 0.45% NaCl
- C. 5% dextrose in 0.9% NaCl
- D. 0.225% NaCl
Correct Answer: C
Rationale: A hypertonic solution has a higher concentration of solutes compared to the intracellular fluid. In this case, 5% dextrose in 0.9% NaCl is hypertonic because it has a higher osmolarity due to the combined effect of dextrose and sodium chloride. The dextrose contributes to the hypertonicity, making the overall solution more concentrated than the intracellular fluid.
The nurse interprets this as?
- A. Respiratory acidosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Metabolic alkalosis
Correct Answer: C
Rationale: Respiratory alkalosis is a condition where there is a decrease in carbon dioxide levels in the blood due to hyperventilation, leading to an increase in pH. In respiratory alkalosis, the body is expelling too much carbon dioxide, causing the blood to become more alkaline. The nurse's interpretation of the situation as respiratory alkalosis suggests that the patient may be breathing rapidly or deeply, resulting in the elimination of excess carbon dioxide and a shift towards alkalosis.