Nursing Elites

1. A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon’s office? Select all that apply.

• A. Hematocrit 30%
• B. Sodium 141 mEq/L
• C. Hemoglobin 8.9 g/dL
• D. Platelets 210,000 cells/mm3

Correct answer: C

Rationale: The correct answer is C. Hemoglobin level of 8.9 g/dL is below the normal range, indicating anemia. Anemia can affect the body's ability to carry oxygen, impacting surgical outcomes. Hematocrit level is an indirect measure of red blood cells, which also reveals anemia when low. Sodium level of 141 mEq/L and platelet count of 210,000 cells/mm3 are within normal ranges and do not require immediate reporting. Abnormal sodium levels can lead to various issues, but in this scenario, it is not a concern for surgical readiness. Platelet count is vital for blood clotting, and a count of 210,000 cells/mm3 is considered normal, so it does not need urgent attention.

2. The nurse is administering intravenous fluids to a dehydrated patient. On the second day of care, the patient's weight has increased by 2.25 pounds. The nurse would expect that the patient's fluid intake has

• A. equaled urine output.
• B. exceeded urine output by 1 L.
• C. exceeded urine output by 2.5 L.
• D. exceeded urine output by 3 L.

Correct answer: B

Rationale: A weight gain of 1 kg, or approximately 2.2 to 2.5 lb, is generally equivalent to 1 liter (L) of fluid retained by the body. In this case, the patient's weight gain of 2.25 pounds suggests an excess fluid retention of approximately 1 liter, indicating that the patient's fluid intake has exceeded urine output by 1 liter. Choices C and D are incorrect as they overestimate the fluid excess based on the patient's weight gain. Choice A is incorrect as it implies an exact balance between fluid intake and urine output, which is not reflected in the given weight increase.

3. After pericardiocentesis for cardiac tamponade, for which signs should the nurse assess the client to determine if tamponade is recurring?

• A. Decreasing pulse
• B. Rising blood pressure
• C. Distant muffled heart sounds
• D. Falling central venous pressure (CVP)

Correct answer: C

Rationale: After pericardiocentesis for cardiac tamponade, the nurse should assess for distant muffled heart sounds that were noted before the procedure. If these sounds return, it could indicate recurring pericardial effusion and potential tamponade. Therefore, the correct answer is the return of distant muffled heart sounds (Option C). Decreasing pulse (Option A) and falling central venous pressure (Option D) are not specific signs of recurring tamponade. Rising blood pressure (Option B) is also not a typical sign of tamponade recurrence; in fact, hypotension is more commonly associated with tamponade.

4. A client with autosomal dominant polycystic kidney disease (ADPKD) asks, “Will my children develop this disease?” How should the nurse respond?

• A. No genetic link is known, so your children are not at increased risk.
• B. Your sons will develop this disease because it has a sex-linked gene.
• C. Only if both you and your spouse are carriers of this disease.
• D. Each of your children has a 50% risk of having ADPKD.

Correct answer: D

Rationale: Children whose parent has the autosomal dominant form of PKD have a 50% chance of inheriting the gene that causes the disease. ADPKD is transmitted as an autosomal dominant trait and therefore is not gender-specific. Both parents do not need to have this disorder. Choice A is incorrect because ADPKD has a known genetic link and a definitive mode of inheritance. Choice B is incorrect as ADPKD is not sex-linked but autosomal dominant. Choice C is incorrect because ADPKD follows an autosomal dominant inheritance pattern and does not require both parents to be carriers for the child to inherit the disease.

5. A nurse administers scopolamine as prescribed to a client in preparation for surgery. For which side effect of this medication does the nurse monitor the client?

• A. Pupil constriction
• B. Increased urine output
• C. Complaints of dry mouth
• D. Complaints of feeling sweaty

Correct answer: D

Rationale: The correct answer is D: 'Complaints of feeling sweaty.' Scopolamine, an anticholinergic medication, commonly causes the side effect of decreased sweating, not increased urine output or pupil constriction. While dry mouth is a possible side effect, it is less likely than the altered sweating pattern. Therefore, the nurse should monitor the client for complaints of feeling sweaty due to the potential side effect of decreased sweating associated with scopolamine.

Similar Questions