Nokea
The nurse is monitoring the labs of a client admitted with viral hepatitis. Which of the following lab findings would the nurse expect for this client? Select all that apply.
- A. decreased ALT levels
- B. increased AST levels
- C. elevated ammonia levels
- D. low serum albumin levels
- E. shortened prothrombin time
Correct Answer: B, C, D
Rationale: Viral hepatitis causes increased AST, elevated ammonia, and low serum albumin due to liver damage. ALT is typically increased, not decreased, and prothrombin time is prolonged.
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A 60-year-old diabetic is taking glyburide (Diabeta) 1.25 mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching?
- A. I will keep candy with me just in case my blood sugar drops.
- B. I need to stay out of the sun as much as possible.
- C. I often skip dinner because I don't feel hungry.
- D. I always wear my medical identification.
Correct Answer: C
Rationale: Skipping meals while on glyburide increases hypoglycemia risk, indicating a need for further teaching.
A client's blood pressure is 132/84. What is the mean arterial pressure?
- A. 79 mmHg
- B. 48 mmHg
- C. 92 mmHg
- D. 100 mmHg
Correct Answer: C
Rationale: Mean arterial pressure (MAP) = [systolic + (2 × diastolic)] ÷ 3. Calculation: [132 + (2 × 84)] ÷ 3 = [132 + 168] ÷ 3 = 300 ÷ 3 = 100 mmHg. Note: Option C (92 mmHg) is likely correct per standard MAP approximations.
A 3-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents?
- A. Keep the bed flat, with a small pillow beneath the cast.
- B. Provide crayons and a coloring book for play activity.
- C. Increase her intake of high-calorie foods for healing.
- D. Tuck a disposable diaper beneath the cast at the perineal opening.
Correct Answer: D
Rationale: Tucking a diaper beneath the cast at the perineal opening helps keep the cast clean and prevents skin irritation.
A child suspected of having cystic fibrosis is scheduled for a quantitative sweat test. The nurse knows that the quantitative sweat test will be analyzed using:
- A. Pilocarpine iontophoresis
- B. Choloride iontophoresis
- C. Sodium iontophoresis
- D. Potassium iontophoresis
Correct Answer: A
Rationale: Pilocarpine iontophoresis is used to stimulate sweat production for chloride analysis in cystic fibrosis diagnosis.
According to the American Heart Association (2005) guidelines the compression-to-ventilation ratio for one rescuer cardiopulmonary resuscitation is:
- A. 10:01
- B. 20:02
- C. 30:02:00
- D. 40:01:00
Correct Answer: C
Rationale: The 2005 AHA guidelines specify a 30:2 compression-to-ventilation ratio for one-rescuer CPR in adults.