Questions and 100% Verified Correct Answer
The nurse is assessing a client's laboratory values following administration of
chemotherapy. Which lab value leads the nurse to suspect that the client is
experiencing tumor lysis syndrome (TLS)?
A. Serum PTT of 10 seconds
B. Serum calcium of 5 mg/dl
C. Oxygen saturation of 90%
D. Hemoglobin of 10 g/dl - ✔✔ANSW✔✔..B. Serum calcium of 5 mg/dl.
TLS results in hyperkalemia, hypocalcemia, hyperuricemia, and hyperphosphatemia.
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which
assessment finding should the nurse expect this client to exhibit?
A. Lower left quadrant pain and a low-grade fever
B. Severe pain at McBurney's point and nausea.
C. Abdominal pain and intermittent tenesmus
D. Exacerbations of severe diarrhea - ✔✔ANSW✔✔..A. Lower left quadrant pain and a
low-grade fever.
Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is the most
common area for diverticula, and the inflammation of diverticula causes a low-grade
fever.
During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest
is not moving. What action should the nurse take first?
A. Use a laryngoscope to check for a foreign body lodged in the esophagus.
B. Reposition the head to validate that the head is in the proper position to open the
airway.
, C. Turn the client to the side and administer three back blows.
D. Perform a finger sweep of the mouth to remove any vomitus - ✔✔ANSW✔✔..B.
Reposition the head to validate that the head is in the proper position to open the
airway.
The most frequent cause of inadequate aeration of the client's lungs during CPR is
improper positioning of the head resulting in occlusion of the airway. A foreign body can
occlude the airway, but this is not common unless choking preceded the cardiac
emergency, and should not be the nurse's first action.
A client is admitted to the hospital with a medical diagnosis of pneumococcal
pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such
as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor because:
A. They occur in the lower love alveoli which are more sensitive to infection
B. Gram-negative organisms are more resistant to antibiotic therapy
C. They occur in healthy young adults who have recently been debilitated by an upper
respiratory infection.
D. Gram-negative pneumonias usually affect infants and small children. -
✔✔ANSW✔✔..B. Gram-negative organisms are more resistant to antibiotic therapy
The gram-negative organisms are resistant to drug therapy which makes recovery very
difficult. Gram-negative pneumonias affect all lobes of the lung. The mean age for
contracting this type of pneumonia is 50 years, and it usually strikes debilitated persons
such as alcoholics, diabetics, and those with chronic lung diseases.
Which intervention should the nurse plan to implement when caring for a client who has
just undergone a right above-the-knee amputation?
A. Maintain the residual limb on three pillows at all times.
B. Place a large tourniquet at the client's bedside
C. Apply constant, direct pressure to the residual limb.
D. Do not allow the client to lie in the prone position. - ✔✔ANSW✔✔..B. Place a large
tourniquet at the client's bedside.
A large tourniquet should be placed in plain sight at the client's bedside. If severe
bleeding occurs, the tourniquet should be readily available and applied to the residual
limb to control hemorrhage. The residual limb should not be place on a pillow because a
flexion contracture of the hip may result. C should be avoided because it may