Nokea
The physician orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result confirms SLE?
- A. Increased total serum complement levels
- B. An above-normal anti-deoxyribonucleic
- C. Negative antinuclear antibody test acid
- D. Negative lupus erythematosus cell test
Correct Answer: B
Rationale: The correct answer is B: An above-normal anti-deoxyribonucleic acid. In SLE, the body produces antibodies against its own DNA, leading to the presence of anti-dsDNA antibodies. Elevated levels of anti-dsDNA antibodies are specific to SLE, confirming the diagnosis.
A: Increased total serum complement levels are seen in SLE due to complement activation but are not specific to SLE.
C: Negative antinuclear antibody test is not consistent with SLE, as ANA positivity is common in SLE.
D: Negative lupus erythematosus cell test is not specific to SLE as lupus erythematosus cells are not always present.
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Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:
- A. A genetic defect in the production of acetylcholine
- B. A reduced amount of neurotransmitter acetylcholine
- C. A decreased number of functioning acetyl-choline receptor sites
- D. An inhibition of the enzyme Ache leaving the end plates folded.
Correct Answer: C
Rationale: The correct answer is C because a decreased number of functioning acetylcholine receptor sites would result in the disease. Acetylcholine is a neurotransmitter that transmits signals between nerves and muscles. If there are fewer receptor sites for acetylcholine to bind to, this can lead to impaired nerve-muscle communication, causing the disease.
Choice A is incorrect because a genetic defect in acetylcholine production would not directly affect the receptor sites. Choice B is incorrect because a reduced amount of acetylcholine would still be able to bind to the available receptor sites. Choice D is incorrect because inhibiting the enzyme Ache would not directly impact the receptor sites.
The nurse caring for an adult client. The nurse will need to monitor for which of the following metabolic complications?
- A. hypoglycemia and hypercalcemia
- B. hyperglycemia and hyperkalemia
- C. hyperglycemia and Hypokalemia
- D. hyperkalemia and hypercalcemia
Correct Answer: C
Rationale: The correct answer is C, hyperglycemia and hypokalemia. Hyperglycemia can occur in adult clients due to various factors such as diabetes or stress. Hypokalemia can be a consequence of hyperglycemia or other conditions leading to potassium loss. Monitoring for these metabolic complications is essential to ensure the client's well-being. Other choices are incorrect because hypoglycemia and hypercalcemia (choice A) are less likely to occur concurrently in adult clients. Hyperglycemia and hyperkalemia (choice B) are less common as hyperkalemia is usually associated with renal dysfunction. Hyperkalemia and hypercalcemia (choice D) are less likely to be monitored together as they are not commonly seen in the same clinical context.
The patient is dangling at the bedside and states, “Oh, my stomach is tearing open.” Which of the following actions should the nurse immediately take when dehiscence occurs?
- A. Have patient sit upright in a chair.
- B. Have patient lie down.
- C. Slow IV fluids.
- D. Obtain a sterile suture set.
Correct Answer: B
Rationale: The correct answer is B: Have patient lie down. When a patient experiences dehiscence (surgical wound separation), lying down helps reduce tension on the wound, minimizing the risk of further tearing. This position also allows the nurse to assess the wound properly. Choice A is incorrect because sitting upright can increase intra-abdominal pressure, worsening the dehiscence. Choice C is incorrect as slowing IV fluids is not a priority in managing dehiscence. Choice D is incorrect because obtaining a sterile suture set should only be done by a healthcare provider and is not the immediate action needed for dehiscence.
Choose the condition that exhibits blood values with a low pH and a high PCO :
- A. Respiratory acidosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Metaboli₂c alkalosis
Correct Answer: A
Rationale: Correct Answer: A: Respiratory acidosis
Rationale:
1. Respiratory acidosis is caused by inadequate ventilation leading to increased PCO₂ and decreased pH.
2. Low pH indicates acidosis, and high PCO₂ indicates respiratory component.
3. Metabolic acidosis (B) results from non-respiratory causes.
4. Respiratory alkalosis (C) is characterized by high pH and low PCO₂.
5. Metabolic alkalosis (D) is caused by non-respiratory factors with high pH.
The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?
- A. Administer the acetaminophen.
- B. Notify the health care provider to obtain a verbal order.
- C. Direct the nursing assistive personnel to give the acetaminophen.
- D. Perform a pain assessment only after administering the acetaminophen.
Correct Answer: A
Rationale: The correct answer is A: Administer the acetaminophen. The rationale is as follows:
1. The patient has a standing order for acetaminjson for headache relief.
2. The nurse has assessed that the patient needs headache relief and has not had the medication in the past 4 hours.
3. Administering the acetaminophen aligns with the prescribed treatment plan and the patient's needs.
Summary:
- Option B is incorrect because obtaining a verbal order is not necessary when there is a standing order.
- Option C is incorrect as nursing assistive personnel should not administer medications without direct supervision.
- Option D is incorrect as pain assessment should precede medication administration to ensure appropriateness.