A nurse is caring for a client who is pregnant and Rh-negative. The nurse should plan to monitor which of the following maternal laboratory test results to determine maternal-fetal blood incompatibility?

Homocysteine.

Indirect Coombs.

Erythropoietin.

aPTT.

Answer and Explanation

The Correct Answer is B

The indirect Coombs test is used to detect antibodies against foreign red blood cells in the maternal serum. This test can help identify maternal-fetal blood incompatibility, which can cause hemolytic disease of the newborn.

Choice A is wrong because homocysteine is a type of amino acid and is not related to blood compatibility.

Choice C is incorrect because erythropoietin is a hormone that regulates red blood cell production and is not a specific test for detecting maternal-fetal blood incompatibility.

Choice D is not the correct answer as aPTT (activated partial thromboplastin time) is a test used to evaluate blood clotting factors and is not directly related to monitoring maternal-fetal blood incompatibility.

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Correct Answer is A

Explanation

Muscle irritability. A client with a lithium level of

2.0 mEq/L has severe lithium toxicity, which can cause muscle irritability, tremors, seizures, and other neurological symptoms. The normal therapeutic range for lithium is 0.8-1.2 mEq/L.

Choice B is wrong because constipation is not a sign of lithium toxicity, but rather a possible side effect of lithium therapy at lower doses.

Choice C is wrong because hypoglycemia is not a sign of lithium toxicity, but rather a possible complication of diabetes or other conditions that affect blood sugar levels.

Choice D is wrong because increased blood pressure is not a sign of lithium toxicity, but rather a possible risk factor for cardiovascular disease or other conditions that affect blood vessels.

A. “I’m urinating in larger amounts.” B. “I have to sleep sitting up.” C. “I suck on hard candy for my dry mouth.” D. “I’ve lost 3 pounds in the last week.”

Correct Answer is B

Explanation

This statement indicates that the client has orthopnea, which is a sign of worsening heart failure and fluid overload. The nurse should intervene by assessing the client’s vital signs, oxygen saturation, lung sounds, and edema, and notifying the provider for possible diuretic adjustment.

Choice A is wrong because “I’m urinating in larger amounts.” is an expected outcome of taking furosemide, which is a loop diuretic that increases urine output and reduces fluid retention.

Choice C is wrong because “I suck on hard candy for my dry mouth.” is a harmless way to cope with the side effect of dry mouth caused by furosemide.

Choice D is wrong because “I’ve lost 3 pounds in the last week.” is a positive sign that the client is losing excess fluid and improving their heart failure

condition. A weight loss of 2 to 4 pounds per week is acceptable for clients taking diuretics.

Normal ranges for heart failure clients are:

Blood pressure: less than 140/90 mmHg
Heart rate: 60 to 100 beats per minute
Respiratory rate: 12 to 20 breaths per minute
Oxygen saturation: greater than 95%
Weight: stable or decreasing within 2 to 4 pounds per week

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A nurse is caring for a client who is pregnant and Rh-negative. The nurse should plan to monitor which of the following maternal laboratory test results to determine maternal-fetal blood incompatibility?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing a client’s laboratory results prior to administering the client’s medications. The nurse notes that the client’s lithium level is 2.0 mEq/L. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is caring for a client who has heart failure and is taking furosemide. Which of the following statements by the client indicates a need for the nurse to intervene?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about delegating tasks to assistive personnel (AP). Which of the following task-specific information should the nurse identify as a contraindication to delegating a task to an AP?

A nurse is collecting data from a 24-month-old toddler during an annual physical examination. Which of the following findings should the nurse report to the provider?

A nurse is caring for a client who is pregnant and Rh-negative. The nurse should plan to monitor which of the following maternal laboratory test results to determine maternal-fetal blood incompatibility?

A nurse is collecting data from a client who is recovering from a recent stroke. Which of the following findings should indicate to the nurse the need for a referral to a speech-language pathologist?

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