A nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily. Which of the following laboratory values is the priority for the nurse to assess?

Antidiuretic hormone (ADH)

Amylase

Aspartate aminotransferase (AST)

Creatinine

Answer and Explanation

The Correct Answer is C

A. Antidiuretic hormone (ADH) levels are not typically affected by alcohol or acetaminophen use.
B. Amylase levels are related to pancreatic function and are not specifically affected by alcohol or acetaminophen use.
C. Aspartate aminotransferase (AST) is a liver enzyme that can be elevated in alcohol-induced liver damage and acetaminophen toxicity.
D. Creatinine levels assess kidney function and are not typically affected by alcohol or acetaminophen use to the extent that AST levels are.

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Correct Answer is B

Explanation

A. Positioning the wrapped package with the outer flap away helps maintain sterility when opening.
B. Holding gauze packages 15 cm (6 in) above the sterile field is incorrect; sterile items should be held at least 15 cm (6 in) above the sterile field to maintain sterility.
C. Holding a bottle of solution with the label away from the palm helps prevent contamination.
D. Wearing sterile gloves when handling sterile items on the sterile field helps maintain sterility.

A. Check the IV site for bleeding every 8 hr B. Obtain a rectal temperature every 8 hr. C. Check the client for proteinuria. D. Limit, IM injections.

Correct Answer is D

Explanation

A. Checking the IV site for bleeding is important for clients with low platelet counts, but it should be monitored more frequently, ideally every 1-2 hours.
B. Obtaining a rectal temperature is routine nursing care but does not specifically address the risk associated with the client's platelet count.
C. Checking for proteinuria may be relevant in other conditions but is not directly related to the client's current hematologic condition.
D. Limiting IM injections is crucial in clients with leukemia and low platelet counts to prevent bleeding complications from puncture sites.

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A nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily. Which of the following laboratory values is the priority for the nurse to assess?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?

Correct Answer is B

Explanation

A nurse is planning care for a client who has leukemia and a platelet count of 130,000/mm3. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is D

Explanation

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