Nokea
A 9-week-old infant is scheduled for cleft lip repair. Which information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite?
- A. Red blood cell count of 2.3 million/mm³
- B. White blood cell count of 10,000/mm³
- C. Weight gain of 2 pounds since birth
- D. Urine specific gravity is 1.011
Correct Answer: A
Rationale: The correct answer is A because a low red blood cell count may indicate anemia, which could pose risks during surgery. Anemia can affect oxygen delivery to tissues, impacting wound healing and overall surgical outcomes. The other options, such as white blood cell count, weight gain, and urine specific gravity, are less critical for immediate surgical considerations. White blood cell count is more related to infection risk postoperatively rather than immediate surgical risk. Weight gain reflects good overall growth but does not impact the immediate surgical situation. Urine specific gravity is more indicative of hydration status rather than immediate surgical risk.
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A 4-year-old child with a history of asthma is brought to the clinic with a complaint of cough and wheezing. The nurse notes that the child has been using a rescue inhaler more frequently over the past week. What should the nurse do next?
- A. Review the child's asthma action plan
- B. Administer a dose of the rescue inhaler
- C. Instruct the parents to increase the dose of the controller medication
- D. Schedule a follow-up appointment in one week
Correct Answer: A
Rationale: In this scenario, the best course of action for the nurse is to review the child's asthma action plan. By doing so, the nurse can assess the current asthma management, ensure that the child is using the rescue inhaler correctly, and make any necessary adjustments to the treatment plan. Reviewing the asthma action plan helps in identifying triggers, proper use of medications, and when to seek medical help. Administering a dose of the rescue inhaler without assessing the current management plan may not address the underlying issue. Instructing the parents to increase the dose of the controller medication without proper evaluation can lead to inappropriate medication adjustments. Scheduling a follow-up appointment in one week is not the immediate action needed to address the child's current symptoms.
Which statement by a school-aged client going to summer camp indicates the best understanding of the mode of transmission of Lyme disease?
- A. I'll cover my mouth with a wet cloth if there's too much dust blowing.
- B. Cuts and scrapes need to be washed out and covered right away.
- C. I'm not going to swim where the water is standing still or feels too hot.
- D. I have to wear long sleeves and pants when we're hiking around the pond.
Correct Answer: D
Rationale: The correct answer is D. Wearing long sleeves and pants is an effective measure to prevent tick bites, which can transmit Lyme disease. Ticks are commonly found in wooded areas and tall grass, so covering exposed skin helps reduce the risk of tick bites and subsequently lowers the risk of contracting Lyme disease. Choices A, B, and C do not directly address the mode of transmission of Lyme disease. Option A pertains to respiratory protection against dust, Option B focuses on wound care, and Option C relates to water safety, none of which are directly related to preventing Lyme disease transmission.
The nurse is conducting an admission assessment of an 11-month-old infant with CHF who is scheduled for repair of restenosis of coarctation of the aorta that was repaired 4 days after birth. Findings include blood pressure higher in the arms than the lower extremities, pounding brachial pulses, and slightly palpable femoral pulses. What pathophysiologic mechanisms support these findings?
- A. The aortic semilunar valve obstructs blood flow into the systemic circulation
- B. The lumen of the aorta reduces the volume of the blood flow to the lower extremities
- C. The pulmonic valve prevents adequate blood volume into the pulmonary circulation
- D. An opening in the atrial septum causes a murmur due to a turbulent left to right shunt
Correct Answer: B
Rationale: The findings are consistent with coarctation of the aorta, where narrowing of the aorta leads to decreased blood flow to the lower extremities. This results in higher blood pressure in the arms compared to the lower extremities, pounding brachial pulses, and slightly palpable femoral pulses. Choices A, C, and D are incorrect because they do not align with the pathophysiological mechanisms of coarctation of the aorta, which specifically involves narrowing of the aortic lumen reducing blood flow to the lower extremities.
After reinforcing information on treating a sprained ankle, what statement by the adolescent indicates to the practical nurse that further instruction is needed?
- A. Keep the leg elevated when sitting.
- B. Wrap the ankle in an elastic bandage for support.
- C. Apply warm compresses to the ankle for the first 24 hours.
- D. Put an ice pack on the ankle, alternating 30 minutes on and 30 minutes off.
Correct Answer: C
Rationale: The correct answer is C. Applying warm compresses to a sprained ankle within the first 24 hours is incorrect as it can increase swelling and inflammation. Instead, cold compresses are recommended to help reduce swelling and pain. Option A, keeping the leg elevated, helps in reducing swelling. Option B, wrapping the ankle in an elastic bandage, provides support. Option D, using an ice pack in intervals, is effective in reducing swelling and pain. Therefore, the statement about applying warm compresses indicates the need for further instruction.
What information should be reinforced with the parents of a school-aged child about Reye's syndrome?
- A. Vaccinate your child before the age of 7 against Reye's syndrome.
- B. Keep the child at home for 2 days after the symptoms appear.
- C. Avoid giving any medication containing aspirin during a viral illness.
- D. Do not provide any citrus juices during a bacterial or viral illness.
Correct Answer: C
Rationale: The correct answer is C: 'Avoid giving any medication containing aspirin during a viral illness.' It is crucial to advise parents to avoid giving any medication containing aspirin during a viral illness to prevent Reye's syndrome. Reye's syndrome is a rare but serious condition linked to the use of aspirin during viral illnesses in children and teenagers. Choices A, B, and D are incorrect because vaccinating against Reye's syndrome is not applicable as there is no specific vaccine for it, keeping the child at home for 2 days after symptoms appear is not a preventive measure for Reye's syndrome, and avoiding citrus juices is not directly related to the prevention of Reye's syndrome.