Nokea
Which organ(s) is/are most at risk for dysfunction in a patient with a potassium level of 6.3 mEq/L?
- A. Lungs
- B. Liver
- C. Kidneys
- D. Heart
Correct Answer: D
Rationale: The correct answer is D: Heart. A potassium level of 6.3 mEq/L indicates hyperkalemia, which can lead to cardiac arrhythmias and even cardiac arrest. The heart is highly sensitive to potassium levels, as it plays a crucial role in regulating the heart's electrical activity. Elevated potassium levels can disrupt this balance, leading to serious cardiac complications.
Summary:
A: Lungs - Not directly affected by potassium levels.
B: Liver - Not directly affected by potassium levels.
C: Kidneys - Kidneys regulate potassium levels but are not the most at risk for dysfunction in this scenario.
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When evaluating the effectiveness of nursing interventions for sinusitis discomfort, which of the following does the nurse assess?
- A. WBC count
- B. Capillary refill
- C. Amount and color of sinus drainage
- D. Comfort level
Correct Answer: C
Rationale: The correct answer is C: Amount and color of sinus drainage. Assessing the amount and color of sinus drainage is crucial in evaluating the effectiveness of nursing interventions for sinusitis discomfort as it indicates the presence of infection or inflammation. Changes in color or amount can signify improvement or worsening of the condition. WBC count (A) may indicate infection but doesn't directly reflect sinusitis discomfort. Capillary refill (B) assesses circulation, not sinusitis. Comfort level (D) is subjective and can vary among individuals, making it less reliable for assessing the effectiveness of interventions.
A 36 y.o. woman who has had no prenatal care comes into the hospital in active labor for her fourth child. She has vesicles evident on her perineum. The following nursing actions are appropriate to protect the unborn baby and the staff, EXCEPT:
- A. Maintain standard precautions
- B. Prepare for the possibility that the baby may be delivered by CS.
- C. Notify the obstetrician and nurse midwife about the vesicles as soon as possible.
- D. Apply antibiotic ointment to the vesicles and place the mother in reverse isolation
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Applying antibiotic ointment and placing the mother in reverse isolation are not appropriate for managing vesicles suspected to be herpes simplex virus (HSV) during labor.
2. HSV can be transmitted to the baby during vaginal delivery, leading to serious consequences.
3. Standard precautions should always be maintained to prevent the spread of infections.
4. Preparing for the possibility of a cesarean section and notifying the obstetrician about the vesicles are important steps to protect the baby and staff from potential harm.
. Which of the following laboratory test results would the nurse expect to find in a client diagnosed with Hashimoto’s thyroiditis?
- A. Thyroxine (T4), 22 ug/dl; triiodothyronine (T3), 320ng/dl; thyroid-stimulating hormone
- B. (TSH) undetectable
- C. T4, 22 ug/dl; T3, 200 ng/dl; TSH 0.1 uIU/ml
- D. T4, 2 ug/dl; t3, 35 ng/dl; TSH 45 uIU/ml
Correct Answer: C
Rationale: Rationale for correct answer C: In Hashimoto's thyroiditis, an autoimmune disorder causing hypothyroidism, we expect to see normal to elevated TSH levels due to the pituitary gland stimulating the thyroid to produce more hormones. T4 and T3 levels may be within normal range or slightly decreased. Choice C reflects this pattern with T4 at 22 ug/dl, T3 at 200 ng/dl, and TSH at 0.1 uIU/ml.
Summary of why other choices are incorrect:
- Choice A: T4 and T3 levels are higher than expected in Hashimoto's thyroiditis, and TSH should be elevated, not stated as normal.
- Choice B: An undetectable TSH level is typically seen in hyperthyroidism, not hypothyroidism like Hashimoto's.
- Choice D: T4 and T3 levels are significantly lower than expected, and TSH is much higher than typically seen in Hashimoto's
Which of the following procedures does the nurse understand is used to correct otosclerosis?
- A. Myringotomy
- B. Mastoidectomy
- C. Myringoplasty
- D. Stapedectomy
Correct Answer: D
Rationale: The correct answer is D: Stapedectomy. This procedure is used to correct otosclerosis by removing the stapes bone and replacing it with a prosthetic device. This restores normal hearing by allowing sound waves to travel through the ear properly. Myringotomy (A) is a procedure to drain fluid from the middle ear, not to correct otosclerosis. Mastoidectomy (B) is the removal of infected mastoid air cells, not related to otosclerosis. Myringoplasty (C) is a surgical procedure to repair a perforated eardrum, not used for otosclerosis. Stapedectomy is the most appropriate choice for correcting otosclerosis as it directly addresses the abnormal bone growth in the middle ear.
A female client with lymphedema expresses her anxiety about the abnormal enlargement of an arm. Which of the ff suggestions should a nurse give to support the clients self image?
- A. Place the arm in the sling
- B. Apply cold soaks to the affected arm
- C. Introduce variations in styles of clothing
- D. Tie a tight bandage to the arm
Correct Answer: C
Rationale: The correct answer is C: Introduce variations in styles of clothing. This suggestion promotes the client's self-image by helping her feel more comfortable and confident in her appearance despite the lymphedema. It allows her to express her personal style while accommodating the enlarged arm.
A: Placing the arm in a sling does not address the client's self-image concerns and may further highlight the abnormality.
B: Applying cold soaks may help with swelling but does not directly address the client's self-image.
D: Tying a tight bandage can worsen lymphedema and does not address the client's self-image concerns.