Nokea
The nurse reviews a 21-year-old female's bloodwork from the lab. Which result would be charted as an abnormal finding?
- A. platelets 129
- B. RBC 4.2
- C. WBC 15.6
- D. hematocrit 38%
Correct Answer: C
Rationale: WBC 15.6 (normal 4.5-11.0 x 10³/μL) is elevated, indicating possible infection or inflammation. Platelets (150-450 x 10³/μL) are slightly low, RBC (4.2-5.4 million/μL) and hematocrit (36-46%) are normal for females.
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Which of the following techniques is recommended for removing a tick from the skin?
- A. Grasping the tick with a tissue and quickly jerking it away from the skin
- B. Placing a burning match close the tick and watching for it to release
- C. Using tweezers, grasp the tick close to the skin and pull the tick free using a steady, firm motion
- D. Covering the tick with petroleum jelly and gently rubbing the area until the tick releases
Correct Answer: C
Rationale: Using tweezers to pull the tick steadily minimizes the risk of leaving mouthparts in the skin.
The oncology nurse is caring for a 24-year-old male client with testicular cancer. Cisplatin IV has been ordered. Which lab value would the nurse notify the health care provider about before administering this medication?
- A. iron 129 mcg/dL
- B. ammonia level 52 mcg/dL
- C. creatinine clearance 23 mL/minute
- D. brain natriuretic peptides (BNP) 36 pg/mL
Correct Answer: C
Rationale: Cisplatin is nephrotoxic; a creatinine clearance of 23 mL/min indicates impaired renal function, requiring provider notification before administration.
An electrical fire occurs in a client's room shortly after the client returns from the recovery room after repair of a hip fracture with insertion of a prosthesis. What is the best method of removing the client from the room?
- A. Place the client in a wheelchair.
- B. Transfer the client to a gurney.
- C. Move the bed with the client on it.
- D. Do a two-person carry.
Correct Answer: C
Rationale: Moving the bed with the client on it (C) is the safest and fastest method to evacuate a post-surgical client with limited mobility during an emergency like a fire. Other methods (A, B, D) risk injury or delay.
A client on the post-op floor underwent surgery 4 days ago. The night nurse reports to the nurse coming on to dayshift that the client complained all night of pain, even though she received every dose of prescribed pain medication. The client currently rates the pain at a 10 out of 10. The day shift nurse should first
- A. call the physician and ask her to prescribe a different medication.
- B. work with the client on alternative pain relief measures such as guided imagery.
- C. administer the next dose of pain medication, but observe the client swallow it to ensure she is really taking the medication.
- D. complete a full head-to-toe assessment on the client.
Correct Answer: D
Rationale: Persistent severe pain post-op suggests a complication (e.g., infection, hemorrhage). A full assessment is the priority to identify the cause before adjusting treatment.
Which statement is true regarding the infant's susceptibility to pertussis?
- A. If the mother had pertussis, the infant will have passive immunity.
- B. Most infants and children are highly susceptible from birth.
- C. The newborn will be immune to pertussis for the first few months of life.
- D. Infants under 1 year of age seldom get pertussis.
Correct Answer: B
Rationale: Infants are highly susceptible to pertussis from birth, as maternal immunity is minimal, and severe cases are common in this age group.