Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reviewing the laboratory results for a client who is at 32 weeks of gestation.
For which of the following results should the nurse notify the provider?
A. Hgb 12 g/dL
Falls within the normal range for hemoglobin during pregnancy, which is typically between 11-13.5 g/dL. Therefore, it does not require immediate notification to the provider.
B. Platelet count 90,000/mm3
During pregnancy, it is important to monitor the client's platelet count because a low platelet count can indicate a condition called gestational thrombocytopenia or other potential complications such as preeclampsia or HELLP syndrome. A platelet count of 90,000/mm3 is lower than the normal range and should be reported to the provider for further evaluation and management.
C. Hematocrit 37%
Falls within the normal range for hematocrit during pregnancy, which is typically between 33-42%. Therefore, it does not require immediate notification to the provider.
D. Creatinine 0.7 mg/dL
Is within the normal range for creatinine levels and does not indicate any immediate concerns or need for notification to the provider.
This question is an excerpt from Nurse Dive's nursing test bank - VATI PN Comprehensive Predictor 2020 Proctored Exam. Take the full exam now
Full Explanation
b. Platelet count 90,000/mm3.
Explanation:
During pregnancy, it is important to monitor the client's platelet count because a low platelet count can indicate a condition called gestational thrombocytopenia or other potential complications such as preeclampsia or HELLP syndrome. A platelet count of 90,000/mm3 is lower than the normal range and should be reported to the provider for further evaluation and management.
Option a, Hgb 12 g/dL, falls within the normal range for hemoglobin during pregnancy, which is typically between 11-13.5 g/dL. Therefore, it does not require immediate notification to the provider.
Option c, Hematocrit 37%, also falls within the normal range for hematocrit during pregnancy, which is typically between 33-42%. Therefore, it does not require immediate notification to the provider.
Option d, Creatinine 0.7 mg/dL, is within the normal range for creatinine levels and does not indicate any immediate concerns or need for notification to the provider.
It is important to remember that the interpretation of laboratory results should be done in the context of the client's individual clinical presentation and the healthcare provider's assessment. Any concerns or abnormal findings should be communicated to the provider for further evaluation and appropriate management.
Similar Questions
A nurse is reinforcing teaching with a client who is about to undergo an upper gastrointestinal series with fluoroscopy. Which of the following information should the nurse provide?
A. You will receive an injection of contrast dye during the test
B. Consume a clear liquid breakfast on the day of the procedure
C. Someone should drive you home after the procedure
D. You will have to drink a contrast medium before the test
The nurse should inform the client that they will have to drink a contrast medium before the upper gastrointestinal series with fluoroscopy. This contrast medium helps visualize the gastrointestinal tract during the procedure. Option a is incorrect because the contrast dye is typically administered orally, not through injection. Option b is incorrect because the client is usually required to have a restricted diet, such as fasting or consuming only clear liquids, prior to the procedure. Option c is incorrect because the client can typically drive themselves home after the procedure as it does not involve sedation or anesthesia
A nurse is collecting data from a client who received IV morphine for postoperative pain. The nurse should identify that which of the following findings indicates a therapeutic response to the medication?
A. The client's blood pressure has been reduced.
While morphine can lower blood pressure due to its vasodilatory effects, a reduction in blood pressure is not necessarily a primary indicator of a therapeutic response to pain relief. It is more important to assess pain relief directly through the client's subjective experience and behavior rather than focusing on vital signs alone.
B. The client exhibits diaphoresis
Diaphoresis, or sweating, can occur as a side effect of morphine administration but does not indicate that the medication is effectively relieving pain. In fact, diaphoresis might signal an adverse reaction or discomfort rather than a therapeutic effect.
C. The client is not grimacing
The absence of grimacing suggests that the client's pain has decreased, which is a direct indicator of a therapeutic response to morphine. Observing a reduction in pain-related behaviors, such as grimacing, is a key assessment for determining the effectiveness of pain management in postoperative clients.
D. The client has an elevated heart rate
An elevated heart rate may be a sign of unresolved pain or a side effect of morphine but is not a clear indicator of pain relief. Effective pain management with morphine typically results in a decrease in sympathetic nervous system responses, such as a high heart rate, rather than an increase.
Full Explanation
Answer: (C) The client is not grimacing
Rationale:
A) The client's blood pressure has been reduced:
While morphine can lower blood pressure due to its vasodilatory effects, a reduction in blood pressure is not necessarily a primary indicator of a therapeutic response to pain relief. It is more important to assess pain relief directly through the client's subjective experience and behavior rather than focusing on vital signs alone.
B) The client exhibits diaphoresis:
Diaphoresis, or sweating, can occur as a side effect of morphine administration but does not indicate that the medication is effectively relieving pain. In fact, diaphoresis might signal an adverse reaction or discomfort rather than a therapeutic effect.
C) The client is not grimacing:
The absence of grimacing suggests that the client's pain has decreased, which is a direct indicator of a therapeutic response to morphine. Observing a reduction in pain-related behaviors, such as grimacing, is a key assessment for determining the effectiveness of pain management in postoperative clients.
D) The client has an elevated heart rate:
An elevated heart rate may be a sign of unresolved pain or a side effect of morphine but is not a clear indicator of pain relief. Effective pain management with morphine typically results in a decrease in sympathetic nervous system responses, such as a high heart rate, rather than an increase.
A nurse is caring for a newborn following a circumcision. Which of the following manifestations indicates
the newborn is experiencing pain?
A. Diaphoresis
None
B. Hypoglycemia
None
C. Lip smacking
Lip smacking in a newborn following circumcision can indicate pain. It is a nonverbal cue that suggests discomfort or distress. Diaphoresis (option a) refers to excessive sweating and can be a sign of pain or other physiological responses. Hypoglycemia (option b) is low blood sugar and is not directly related to pain. Transient strabismus (option d) refers to temporary misalignment of the eyes and is not specifically indicative of pain.
D. Transient strabismus
None