Nokea
Which laboratory value would you report to the doctor because it is not normal and it is also a significant change in the client?
- A. Albumin: 40 g/L
- B. Amylase: 40 U/L
- C. Direct bilirubin: 17 umol/L
- D. Total bilirubin: 17 umol/L
Correct Answer: D
Rationale: Total bilirubin of 17 umol/L (1 mg/dL) is elevated (normal 0.1-1.0 mg/dL), indicating potential liver or biliary issues, requiring reporting.
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The nurse is planning care for a client who has sustained a spinal cord injury. The nurse should assess the client for:
- A. Anesthesia below the level of the injury.
- B. Tingling in the fingers.
- C. Pain below the site of the injury.
- D. Loss of position and vibratory sense.
Correct Answer: A,D
Rationale: Spinal cord injury often causes anesthesia (loss of sensation) and loss of position/vibratory sense below the injury level. Tingling or pain below the injury is less likely due to disrupted nerve pathways.
The nurse is caring for a client post-myocardial infarction. Which activity should the nurse encourage to promote recovery?
- A. Bed rest for 48 hours
- B. Light ambulation as tolerated
- C. Heavy lifting after 24 hours
- D. High-intensity exercise
Correct Answer: B
Rationale: Light ambulation as tolerated promotes circulation and prevents complications like deep vein thrombosis, while avoiding overexertion post-myocardial infarction.
A client with a history of tuberculosis is prescribed isoniazid. Which supplement should the nurse administer concurrently?
- A. Vitamin C
- B. Vitamin B6
- C. Vitamin D
- D. Vitamin K
Correct Answer: B
Rationale: Isoniazid can cause peripheral neuropathy due to vitamin B6 deficiency, so pyridoxine (vitamin B6) is administered to prevent this side effect.
Which interventions should the nurse include in the plan of care for a client who is scheduled for a bronchoscopy? Select all that apply.
- A. Remove any dentures.
- B. Remove contact lenses.
- C. Provide access to limited food and drink.
- D. Ensure that the informed consent is signed.
- E. Have the client void before transport to endoscopy.
Correct Answer: A,B,D,E
Rationale: If the client has any contact lenses, dentures, or other prostheses, they are removed before sedation is administered to him or her. The client must sign an informed consent because the procedure is invasive. For comfort reasons, the client also should be asked about the need to void before transport to the endoscopy department. The client is not allowed to eat or drink usually for 6 to 8 hours (or as specified by the primary health care provider) before the procedure to prevent the risk of aspiration.
The nurse is caring for a client with a history of burns. Which of the following complications should the nurse monitor for in the acute phase?
- A. Hypovolemia.
- B. Hypernatremia.
- C. Hypoglycemia.
- D. Respiratory alkalosis.
Correct Answer: A
Rationale: Hypovolemia is a major complication in the acute phase of burns due to fluid loss.