A nurse is assessing laboratory values on a client who has taken an overdose of acetaminophen. The nurse should expect which of the following laboratory values indicative of organ damage from the overdose?
Alanine aminotransferase (ALT)
Thyroxine (T4)
Serum amylase
Creatinine kinase (CK)
The Correct Answer is A
A. Alanine aminotransferase (ALT): ALT is an enzyme found primarily in the liver, and elevated levels indicate hepatocellular injury. Acetaminophen overdose can cause severe liver toxicity, so a rise in ALT reflects liver damage and is a key laboratory marker to monitor in this situation.
B. Thyroxine (T4): Thyroxine is a thyroid hormone and is unrelated to liver injury or acetaminophen toxicity. Changes in T4 levels do not provide information about organ damage resulting from an overdose.
C. Serum amylase: Serum amylase is an enzyme associated with pancreatic function. While elevated amylase indicates pancreatitis, it is not typically affected by acetaminophen overdose and does not reflect hepatotoxicity.
D. Creatinine kinase (CK): CK is an enzyme released from muscle tissue during injury or breakdown. While important in assessing muscle damage or rhabdomyolysis, it does not indicate liver damage from acetaminophen toxicity.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Herpes simplex virus 2: HSV-2 is a common sexually transmitted infection, but it is not universally reportable to the CDC in all states. While some jurisdictions may require reporting, it is not consistently a nationally notifiable infection.
B. Candida albicans: Candida infections are common opportunistic infections and are not considered reportable to the CDC because they occur frequently and do not typically pose a public health threat. Routine cases are managed at the clinical level.
C. Staphylococcus aureus: Although S. aureus infections, including MRSA, are clinically significant, they are generally not reportable to the CDC unless part of a specific outbreak or public health investigation. Routine cases are not mandatory to report.
D. Lyme disease: Lyme disease is a nationally notifiable infection that must be reported to the CDC. Reporting is essential for surveillance, tracking trends, and implementing public health interventions to reduce disease transmission and prevent outbreaks.
Correct Answer is A
Explanation
A. Collecting a urine specimen: This task is routine, noninvasive, and does not require nursing judgment, making it appropriate for delegation to assistive personnel. APs are trained to obtain clean-catch or routine urine specimens while following proper technique. Delegating this task allows the nurse to focus on interventions requiring professional judgment.
B. Measuring a client's pain level: Pain assessment requires clinical judgment and involves interpreting verbal and nonverbal cues. Determining the severity, characteristics, and impact of pain is a nursing responsibility. Because it directly influences clinical decisions and interventions, it cannot be delegated to assistive personnel.
C. Monitoring blood glucose levels: Although APs in some settings may perform point-of-care glucose checks, this task generally requires specific training and competency validation. Interpretation of results and subsequent actions rely on nursing assessment, making it less appropriate for routine delegation unless the facility has clear protocols allowing it.
D. Adjusting the flow rate of a client's oxygen tank: Oxygen therapy adjustment involves evaluating the client’s respiratory status and making changes that can affect ventilation and oxygenation. Altering flow rates requires nursing judgment to ensure safety and prevent complications such as hypoxia or CO₂ retention.
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