Nokea
The nurse is inspecting the tonsils for a client with a fever and sore throat. The nurse observes purulent exudate on the surface of the tonsils. What does this finding indicate to the nurse?
- A. Filariasis
- B. Thrush
- C. An abscess
- D. Tonsillitis
Correct Answer: D
Rationale: Purulent exudate on the surface of the tonsils suggests tonsillitis. Filariasis is also known as elephantiasis and is a consequence of a roundworm infection in which the lymphatic vessels become occluded. An abscess would not have purulent drainage on the surface unless ruptured.
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A client is brought to the emergency department with suspected bleeding esophageal varices. Which hemoglobin level should the nurse immediately report to the physician?
- A. 13.0 g/dL
- B. 10.2 g/dL
- C. 5.0 g/dL
- D. 11.4 g/dL
Correct Answer: C
Rationale: The nurse should immediately report a 5.0 g/dL, which is a critical low level. A 13.0 g/dL is a normal level, 11.4 is slightly low, and 10.2 is low.
A client has type AB blood. What type of blood must this client receive during a blood transfusion?
- A. They can receive blood from persons with any type of blood if the RH factor is compatible.
- B. They can only receive blood from persons with type A blood.
- C. They can only receive blood from persons with type B blood.
- D. They can only receive blood from persons with type O blood if the RH factor is positive.
Correct Answer: A
Rationale: People with type AB blood are considered universal recipients because both A and B antigens are present on the red cell membrane. Clients with type AB blood can receive blood from persons with any type of blood, but the Rh factor must be compatible. The other distractors are incorrect because the client can receive blood from any type.
A client is seeing the physician at the clinic and tells the nurse he is fatigued and short of breath with minimal exertion. What lab study may reflect a decrease in transport of oxygen?
- A. Erythrocyte count
- B. Leukocyte count
- C. Platelet count
- D. Albumin level
Correct Answer: A
Rationale: Erythrocytes function is to transport oxygen. Leukocytes protect against infection. Platelets participate in clotting blood, and albumin affects intravascular osmotic pressure.
A client's family member asks what hematopoiesis is. What should the nurse tell the family member?
- A. The manufacture and development of blood cells
- B. The production of lymphatic fluid in the body
- C. The making of red blood cells and lymph
- D. The development of lymph in the bone marrow
Correct Answer: A
Rationale: Hematopoiesis is the manufacture and development of blood cells. It also considers the lymphatic system, which includes the thymus gland and spleen; this system assists in the maturation of certain lymphocytes. Hematopoiesis is not the production of lymphatic fluid or the development of lymph in the bone marrow.
A nurse is providing care to a cancer client. Which protein in plasma functions primarily as immunologic agents?
- A. Gamma globulins
- B. Albumin
- C. Fibrinogen
- D. Beta globulins
Correct Answer: A
Rationale: Globulins are divided into three groups: alpha, beta, and gamma. The gamma globulins are also called immunoglobulins. Globulins function primarily as immunologic agents; they prevent or modify some types of infectious diseases. The other options are incorrect.