Nokea
The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?
- A. Collect the blood sample
- B. Assess radial pulse volume
- C. Apply pressure to the site
- D. Select another finger
Correct Answer: A
Rationale: The reddened and engorged appearance is due to increased blood flow, and the sample can still be collected.
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The pH of urine:
- A. Is a useful indicator of the acid/base balance of blood
- B. Rises on a vegetarian diet
- C. Is determined by the concentration of ammonium
- D. Is lower than 5.5 in renal tubular acidosis
Correct Answer: A
Rationale: Urine pH reflects blood acid/base balance. A vegetarian diet typically raises urine pH, and renal tubular acidosis causes a higher pH, not lower.
A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?
- A. Prepare for transcutaneous pacing
- B. Deliver another defibrillator shock
- C. Administer IV Epinephrine per ACLS protocol
- D. Give IV dose of adenosine rapidly over 1-2 seconds
Correct Answer: D
Rationale: The client may experience arrhythmia, and the correct intervention is giving IV adenosine to slow the heart rate.
Biochemical abnormalities in a chronic carrier of hepatitis B are:
- A. Raised AST
- B. Low serum albumin
- C. Raised gamma GT
- D. Raised transferrin
Correct Answer: A
Rationale: The correct answer is A because chronic hepatitis B carriers often have raised AST (aspartate aminotransferase) due to liver inflammation. The other options are less specific or not typically associated with chronic hepatitis B.
Which vaccines must be delayed for 11 months after the administration of gamma globulin? (Select all that apply.)
- A. Diphtheria, tetanus, and pertussis
- B. Hepatitis B
- C. Inactivated polio virus
- D. Measles, mumps, and rubella
Correct Answer: D
Rationale: Live virus vaccines (MMR and Varicella) should be delayed for 11 months after gamma globulin infusion because the passive antibodies can interfere with vaccine efficacy.
For one of the following, total repair is really achieved, with no requirement for long-term follow-up
- A. atrial septal defects
- B. ventricular septal defects
- C. pulmonic stenosis
- D. uncomplicated isolated pulmonic stenosis
Correct Answer: D
Rationale: Uncomplicated isolated pulmonic stenosis can often be repaired with no need for long-term follow-up.