Nokea
Which lipid level would you report to the doctor because it is not normal and it is also a significant change in the client?
- A. Triglycerides: 75 mg/dL
- B. Total cholesterol: 6.5 mmol/L
- C. High-density lipoprotein (HDL): 60 mg/dL
- D. Low-density lipoprotein (LDL): 955 mg/dL
Correct Answer: D
Rationale: LDL of 955 mg/dL is extremely high (normal <130 mg/dL), indicating a significant risk for cardiovascular disease and requiring immediate reporting.
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The nurse is teaching a client with a new diagnosis of hyperthyroidism about medication management. Which of the following medications should the client expect to take?
- A. Methimazole.
- B. Levothyroxine.
- C. Liothyronine.
- D. Propylthiouracil.
Correct Answer: A, D
Rationale: Methimazole and propylthiouracil inhibit thyroid hormone production in hyperthyroidism.
The nurse is preparing a poster for a booth at a health fair to promote primary prevention of cervical cancer. Which recommendation should the nurse include on the poster?
- A. Use a commercial douche on a daily basis.
- B. Perform monthly breast self-examination (BSE).
- C. Seek treatment promptly if cervical infection is suspected.
- D. Use oral contraceptives as a preferred method of birth control.
Correct Answer: C
Rationale: Early treatment of cervical infection can help prevent chronic cervicitis, which can lead to dysplasia of the cervix. Cervical dysplasia is an early cell change that is considered to be premalignant. Douches and oral contraceptives do not decrease the risk for this type of cancer. BSE is useful for early detection of breast cancer, but is unrelated to cervical cancer.
The nurse is assigned to care for a client with a chest tube attached to closed chest drainage. Which assessment data should the nurse identify as an indicator that the client's lung has completely expanded?
- A. Pleuritic chest pain has resolved.
- B. The oxygen saturation is greater than 92%.
- C. Fluctuations in the water-seal chamber ceased.
- D. Suction in the chest drainage system is no longer needed.
Correct Answer: C
Rationale: When the lung has completely expanded, there is no longer air in the pleural space causing fluctuations in the water-seal chamber. Thus, an indication that a chest tube is ready for removal is when fluctuations in the water-seal chamber cease. Although air is known to be an irritant to pleural tissue, cessation of pleuritic pain does not indicate that the lung is expanded. The chest tube acts as an irritant and therefore contributes to pain. Adequate oxygen saturation does not imply that the lung has fully reexpanded. Use or nonuse of suction in the chest drainage system is not necessarily governed by the degree of lung expansion. Suction is indicated when gravity is not sufficient to drain air and pleural fluid or if the client has a poor respiratory effort and cough.
The nurse is teaching a client about the use of a peak flow meter for asthma management. The client should be instructed to:
- A. Use it only during an attack
- B. Record the highest of three readings
- C. Clean it with alcohol daily
- D. Use it before exercise only
Correct Answer: B
Rationale: Recording the highest of three peak flow readings provides the most accurate assessment of lung function for asthma monitoring.
When a client states that he is allergic to amoxicillin (Ampicillin) even though his medication administration record and armband do not indicate medication allergies, the nurse should:
- A. Administer the prescribed medication.
- B. Withhold the amoxicillin (Ampicillin).
- C. Administer another, similarly acting antibiotic.
- D. Call the family to verify the client's statement.
Correct Answer: B
Rationale: Withholding the medication is the safest action until the allergy can be verified to prevent an allergic reaction.