Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. The client's skin and eyes are visibly jaundiced.
The client's skin and eyes are visibly jaundiced is correct because jaundice indicates a buildup of bilirubin in the blood, which is a sign of liver dysfunction.
B. The client's AST and ALT levels are elevated.
The client's AST and ALT levels are elevated is correct because elevated levels of these liver enzymes indicate hepatocellular injury, which is consistent with liver damage due to acetaminophen overdose.
C. The client's temperature is 102.5° F (39.2° C).
The client's temperature is 102.5° F (39.2° C) is incorrect; while a fever can occur in various conditions, it is not specific for liver damage in this context.
D. The client has an elevated red blood cell count.
The client has an elevated red blood cell count is incorrect; elevated red blood cell counts are not indicative of liver damage and may be related to other factors.
E. The client's eyes are sensitive to light.
The client's eyes are sensitive to light is incorrect; photophobia is not a direct indicator of liver damage and is more related to other conditions.
This question is an excerpt from Nurse Dive's nursing test bank - Med Surg Exam Antelope Valley College Proctored Exam. Take the full exam now
Full Explanation
A. The client's skin and eyes are visibly jaundiced is correct because jaundice indicates a buildup of bilirubin in the blood, which is a sign of liver dysfunction.
B. The client's AST and ALT levels are elevated is correct because elevated levels of these liver enzymes indicate hepatocellular injury, which is consistent with liver damage due to acetaminophen overdose.
C. The client's temperature is 102.5° F (39.2° C) is incorrect; while a fever can occur in various conditions, it is not specific for liver damage in this context.
D. The client has an elevated red blood cell count is incorrect; elevated red blood cell counts are not indicative of liver damage and may be related to other factors.
E. The client's eyes are sensitive to light is incorrect; photophobia is not a direct indicator of liver damage and is more related to other conditions.
Similar Questions
When administering an opioid antagonist drug to a client, the primary goal of the therapy is to provide:
A. A return to normal respiratory rate, rhythm, and depth.
A return to normal respiratory rate, rhythm, and depth is correct because opioid antagonists, such as naloxone, are primarily used to reverse the respiratory depression caused by opioid overdose.
B. Management of alcohol withdrawal symptoms.
Management of alcohol withdrawal symptoms is incorrect; opioid antagonists do not address alcohol withdrawal.
C. A reduction in the client's rating of their pain.
A reduction in the client's rating of their pain is incorrect; opioid antagonists counteract the effects of opioids, which can result in increased pain levels rather than reduction.
D. Alertness and improve memory function.
Alertness and improve memory function is incorrect; while opioid antagonists may improve alertness by reversing sedation, the primary goal focuses on restoring respiratory function.
Full Explanation
A. A return to normal respiratory rate, rhythm, and depth is correct because opioid antagonists, such as naloxone, are primarily used to reverse the respiratory depression caused by opioid overdose.
B. Management of alcohol withdrawal symptoms is incorrect; opioid antagonists do not address alcohol withdrawal.
C. A reduction in the client's rating of their pain is incorrect; opioid antagonists counteract the effects of opioids, which can result in increased pain levels rather than reduction.
D. Alertness and improve memory function is incorrect; while opioid antagonists may improve alertness by reversing sedation, the primary goal focuses on restoring respiratory function.
A client with a long-standing diagnosis of angina has been prescribed nitroglycerin and diltiazem. In addition to monitoring the client's heart rate, the nurse should prioritize what assessment?
A. Blood pressure
Blood pressure is correct because both nitroglycerin and diltiazem can cause vasodilation, leading to hypotension; thus, monitoring blood pressure is crucial for patient safety.
B. Level of consciousness
Level of consciousness is incorrect; while important, it is not the primary concern in this context.
C. Daily weights
Daily weights are incorrect; they are more relevant for assessing fluid status over time, not immediate drug effects.
D. Respiratory status
Respiratory status is incorrect; while monitoring is important, blood pressure takes precedence due to the risk of hypotension associated with these medications.
Full Explanation
A. Blood pressure is correct because both nitroglycerin and diltiazem can cause vasodilation, leading to hypotension; thus, monitoring blood pressure is crucial for patient safety.
B. Level of consciousness is incorrect; while important, it is not the primary concern in this context.
C. Daily weights are incorrect; they are more relevant for assessing fluid status over time, not immediate drug effects.
D. Respiratory status is incorrect; while monitoring is important, blood pressure takes precedence due to the risk of hypotension associated with these medications.
The nurse is teaching a client how to use nasal spray. What will the nurse include in the teaching plan? (Select all that apply.)
A. Sit up comfortably in the bed.
Sit up comfortably in the bed is incorrect; the client should be in an upright position, which can be done while sitting up comfortably, but it’s essential to emphasize a more upright posture for optimal administration.
B. Tilt the head slightly to the side.
Tilt the head slightly to the side is correct; this position helps facilitate the delivery of the medication into the nasal passages.
C. Insert the tip of the nose piece into one nostril.
Insert the tip of the nose piece into one nostril is correct; proper insertion ensures effective delivery of the medication.
D. Hold the breath for a few seconds after administering the spray.
Hold the breath for a few seconds after administering the spray is correct; this allows the medication to be absorbed more effectively.
E. Blow the nose 1 minute after administering the spray.
Blow the nose 1 minute after administering the spray is incorrect; clients should avoid blowing their nose immediately after use to allow for proper absorption of the medication.
Full Explanation
A. Sit up comfortably in the bed is incorrect; the client should be in an upright position, which can be done while sitting up comfortably, but it’s essential to emphasize a more upright posture for optimal administration.
B. Tilt the head slightly to the side is correct; this position helps facilitate the delivery of the medication into the nasal passages.
C. Insert the tip of the nose piece into one nostril is correct; proper insertion ensures effective delivery of the medication.
D. Hold the breath for a few seconds after administering the spray is correct; this allows the medication to be absorbed more effectively.
E. Blow the nose 1 minute after administering the spray is incorrect; clients should avoid blowing their nose immediately after use to allow for proper absorption of the medication.