Nokea
The physician has ordered a liver panel for a client with suspected hepatitis. Which laboratory result is most indicative of liver damage?
- A. Elevated ALT
- B. Decreased hemoglobin
- C. Elevated sodium
- D. Decreased potassium
Correct Answer: A
Rationale: Elevated alanine aminotransferase (ALT) is specific to liver damage, as it is released when hepatocytes are injured, common in hepatitis. Hemoglobin, sodium, and potassium are not directly indicative of liver function.
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A client has renal failure. Today's lab values indicate he has an elevated serum potassium. What additional priority information does the nurse need to obtain?
- A. Evaluation of his level of consciousness
- B. Evaluation of an electrocardiogram
- C. Measurement of his urine output for the past 8 hours
- D. Serum potassium lab values for the last several days
Correct Answer: B
Rationale: The level of consciousness is not affected by elevated potassium levels. An electrocardiogram (EKG) can tell the nurse whether this client is experiencing any cardiac dysfunction or arrhythmias related to the elevated potassium level. Measurement of the urine output is not a priority nursing action at this time. The client's serum potassium values for the past several days may provide information about his renal function, but they are not a priority at this time.
A 32-year-old female client is being treated for Guillain-Barré syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?
- A. Complaints of a headache
- B. Loss of superficial and deep tendon reflexes
- C. Complaints of shortness of breath
- D. Facial paralysis
Correct Answer: C
Rationale: Headaches are not associated with Guillain-Barré syndrome. Loss of superficial and deep tendon reflexes is expected with this diagnosis. Complaints of shortness of breath must be further evaluated. Forty percent of all clients have some detectable respiratory weakness and should be prepared for a possible tracheostomy. Pneumonia is also a common complication of this syndrome. Facial paralysis is expected and is not considered abnormal.
A client with gallstones and obstructive jaundice is experiencing severe itching. The physician has prescribed cholestyramine (Questran). The client asks, “How does this drug work?” What is the nurse’s best response?
- A. “It blocks histamine, reducing the allergic response.”
- B. “It inhibits the enzyme responsible for bile excretion.”
- C. “It decreases the amount of bile in the gallbladder.”
- D. “It binds with bile acids and is excreted in bowel movements with stool.”
Correct Answer: D
Rationale: Cholestyramine binds bile acids in the intestine, forming complexes excreted in stool, reducing circulating bile acids that cause itching. It doesn’t block histamine (A), inhibit enzymes (B), or reduce gallbladder bile (C).
The nurse is caring for a client with a history of a hysterectomy. The client complains of hot flashes. The nurse should:
- A. Apply a heating pad
- B. Encourage fluid restriction
- C. Discuss hormone replacement therapy
- D. Administer acetaminophen
Correct Answer: C
Rationale: Hot flashes post-hysterectomy are due to hormonal changes. Discussing hormone replacement therapy with the physician is appropriate. Heating pads, fluid restriction, and acetaminophen are ineffective.
A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should:
- A. Notify the physician immediately
- B. Hold the morning lithium dose and continue to observe the client
- C. Administer the morning lithium dose as scheduled
- D. Obtain an order for benztropine (Cogentin)
Correct Answer: C
Rationale: There is no need to phone the physician because the lithium level is within therapeutic range and because there are no indications of toxicity present. There is no reason to withhold the lithium because the blood level is within therapeutic range. Also, it is necessary to give the medication as scheduled to maintain adequate blood levels. The lab results indicate that the client's lithium level is within therapeutic range (0.2-1.4 mEq/L), so the medication should be given as ordered. Benztropine is an antiparkinsonism drug frequently given to counteract extrapyramidal symptoms associated with the administration of antipsychotic drugs (not lithium).