The nurse should expect a prescription for which of the following laboratory tests?
- A. Platelet count
- B. Potassium level
- C. Creatinine clearance
- D. Prealbumin
Correct Answer: A
Rationale: Petechiae and ecchymoses suggest thrombocytopenia warranting platelet count evaluation.
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Which of the following instructions should the nurse include in the teaching?
- A. Place tongue on the mouthpiece of the meter
- B. Maintain a semi-Fowler's position during testing
- C. Record the average of the readings.
- D. Blow into the meter as hard and quickly as possible.
Correct Answer: D
Rationale: The correct answer is D because blowing into the meter as hard and quickly as possible ensures accurate lung function test results. This instruction ensures a consistent and forceful flow of air, which is crucial for reliable readings. Option A is incorrect because the tongue should not be placed on the mouthpiece, as this can affect the accuracy of the test. Option B is incorrect as maintaining a semi-Fowler's position is not necessary for this test. Option C is incorrect because recording the average of the readings is not a step in the actual testing process.
Which of the following findings should the nurse include in the teaching?
- A. Swelling of the face
- B. Bleeding gums
- C. Urinary frequency
- D. Faintness upon rising
Correct Answer: A
Rationale: Facial swelling may indicate preeclampsia requiring prompt evaluation.
Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?
- A. Examine for leakage at the site of the procedure
- B. Compare the client's current weight with preprocedural weight
- C. Confirm that the client is able to urinate.
- D. Check the client's serum albumin levels.
Correct Answer: B
Rationale: The correct answer is B: Compare the client's current weight with preprocedural weight. This is the most appropriate action to evaluate the effectiveness of the procedure because changes in weight can indicate fluid retention or loss, which are common outcomes of many procedures. This comparison helps assess if the procedure had the desired effect on the client's fluid status.
Examine for leakage at the site of the procedure (A) is not the best action to evaluate the procedure's effectiveness as leakage may not always correlate with the overall success of the procedure. Confirming that the client is able to urinate (C) is important but may not directly indicate the effectiveness of the procedure. Checking the client's serum albumin levels (D) is relevant for assessing nutritional status but may not directly evaluate the procedure's effectiveness.
The nurse observes blood on the child's dressing.Which of the following actions should the nurse take?
- A. Apply intermittent pressure 2.5 cm(1 in) below the percutaneous skin site
- B. Apply continuous pressure 2.5 cm(1 in) above the percutaneous skin site
- C. Apply continuous pressure 2.5 cm(1 in) below the percutaneous skin site.
- D. Apply intermittent pressure 2.5 cm(1 in) above the percutaneous skin site
Correct Answer: B
Rationale: Continuous pressure above the site controls bleeding effectively.
Which of the following findings places the client at risk if he receives alteplase?
- A. Family history of malignant hypertension
- B. Hip arthroplasty 1 week ago
- C. Chronic obstructive pulmonary disease
- D. Acute renal failure 6 months ago
Correct Answer: B
Rationale: Recent surgeries increase bleeding risks with thrombolytics.