Nokea
The nurse is inspecting the tonsils of a client that complains of a sore throat for size and appearance. What is the appropriate documentation for an observation of tonsils that touch the uvula?
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: C
Rationale: A scale of 3 is when the tonsils touch the uvula. A 1 is when the tonsils are visible, a 2 is when the tonsils extend medially toward the uvula, and a 4 is when the tonsils touch each other.
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A student nurse is having difficulty understanding the function of globulins. What information can the client provide to the student regarding the function of globulins?
- A. Immunologic agents
- B. Destruction of invading organisms
- C. Precursors to clot formation
- D. Transport of oxygen to the tissues
Correct Answer: A
Rationale: Globulins function primarily as immunologic agents; they prevent or modify some types of infectious diseases. Globulins do not destroy invading organisms, participate in clot formation, or transport oxygen to the tissues.
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.
The nursing instructor is teaching her clinical group about laboratory blood tests. What is the major function of erythrocytes?
- A. Act as mediators for the immune system
- B. Destroy invading organisms
- C. Transportation of Oâ?? to the tissues and removal of COâ?? from the tissues
- D. Oxygenation of the brain
Correct Answer: C
Rationale: Erythrocytes (or RBCs) are flexible, anuclear (lacking a nucleus), biconcave disks covered by a thin membrane through which oxygen (Oâ??) and carbon dioxide (COâ??) pass freely. The flexibility of erythrocytes allows them to change shape as they travel through capillaries. Their major function is to transport Oâ?? to and remove COâ?? from the tissues. The RBCs are not involved in immunological functions, so choices A and B are not correct. Oxygenation of the brain is important but that is not a major function of RBCs.
The nurse will be assisting the physician with a bone marrow aspiration. Where should the nurse cleanse, clip hair, and drape the skin prior to the procedure?
- A. Over the posterior superior iliac crest.
- B. Over the anterior tibia
- C. Over the radius
- D. Over the metatarsal area
Correct Answer: A
Rationale: The posterior superior iliac crest is the preferred site because no vital organs or blood vessels are nearby. The anterior tibia, radius, or metatarsal area are not used for bone marrow aspirations.
A client is being treated for anemia and has a hemoglobin level of 9.6 g/dL. What does the nurse understand is the basic nutritional component of heme in hemoglobin that the client may be deficient in?
- A. Folic acid
- B. Copper
- C. Protein
- D. Iron
Correct Answer: D
Rationale: Iron is the basic nutritional component of heme in hemoglobin. Folic acid is essential for the maturation of red blood cells. Copper (minute amount) is involved in the transfer of iron from storage to plasma.