Nokea
The nurse is reviewing laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires immediate action by the nurse?
- A. glucose 200 mg/dL (11.1 mmol/L)
- B. hematocrit 38% (0.38)
- C. potassium 3.4 mEq/L (3.4 mmol/L)
- D. troponin T 0.7 ng/mL (0.7 mcg/L)
Correct Answer: D
Rationale: Elevated troponin T (0.7 ng/mL) indicates myocardial injury, requiring immediate action for possible myocardial infarction. Other values are less critical.
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The nurse is caring for a school-aged client recently diagnosed with attention deficit hyperactivity disorder. The nurse should recognize that the client is at risk for experiencing
- A. delayed physical development
- B. delusions
- C. low self-esteem
- D. Paranoia
Correct Answer: C
Rationale: Children with ADHD often face challenges with academic performance and social interactions, increasing the risk of low self-esteem. A is not typically associated with ADHD. B and D are more relevant to psychotic disorders, not ADHD.
The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown?
- A. Ileostomy
- B. Transverse colostomy
- C. Ileal conduit
- D. Sigmoid colostomy
Correct Answer: A
Rationale: Ileostomy output contains caustic gastric and enzymatic agents that can denude skin quickly.
An adult asks the nurse about blood types. Which information should the nurse plan to include when replying?
- A. Blood typing is not always accurate.
- B. A person cannot receive a factor that he/she does not have.
- C. The universal donor is AB negative.
- D. A person who is O positive can donate blood to anyone.
Correct Answer: B
Rationale: A person cannot receive blood with antigens (factors) they lack, as it causes an immune reaction. Blood typing is accurate, O negative is the universal donor, and O positive can only donate to Rh-positive types.
The nurse is teaching a mother how to administer eardrops to her children who are 1 and 6 years old. What should be included in the teaching?
- A. Before putting ear drops in your 1-year-old child's ear, pull the ear down and back. Pull the ear up and back before putting ear drops in your 6-year-old child's ear.
- B. Before putting ear drops in your 1-year-old child's ear, pull the ear up and back. Pull the ear down and back before putting ear drops in your 6-year-old child's ear.
- C. Pull the ears down and back before putting eardrops in the ears of both of your children.
- D. Pull the ears up and back before putting eardrops in the ears of both of your children.
Correct Answer: A
Rationale: To straighten the ear canal of infants and toddlers, the ear needs to be pulled down and back. To straighten the ear canal of older children, the ear should be pulled up and back.
A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse?
- A. a report of 10 pounds weight loss in the last month
- B. a comment by the client 'I just can't sit still.'
- C. the appearance of eyeballs that appear to 'pop' out of the client's eye sockets
- D. a report of the sudden onset of irritability in the past 2 weeks
Correct Answer: C
Rationale: Exophthalmos or protruding eyeballs is a distinctive characteristic of Graves' Disease. It can result in corneal abrasions with severe eye pain or damage when the eyelid is unable to blink down over the protruding eyeball. Eye drops or ointment may be needed.