Nokea
A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention?
- A. Urinary output less than intake
- B. Bruising at the insertion site
- C. Slurred speech and confusion
- D. Discomfort in the left leg
Correct Answer: C
Rationale: Slurred speech and confusion may indicate a neurological complication, such as a stroke, which requires immediate intervention.
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An adolescent who sustained a tibia fracture in a motor vehicle accident has a cast. What should the nurse do to help relieve the itching?
- A. Apply cool air under the cast with a blow-dryer
- B. Use sterile applicators to scratch the itch
- C. Apply cool water under the cast
- D. Apply hydrocortisone cream under the cast using sterile applicator
Correct Answer: A
Rationale: Cool air helps relieve itching without damaging the cast or introducing moisture, which can lead to skin breakdown.
Regarding cystic fibrosis:
- A. It is inherited as autosomal recessive
- B. There is increased risk of bronchial carcinoma in late adulthood
- C. Biliary cirrhosis is a recognised feature
- D. In neonates, intestinal obstruction may be the first presentation
Correct Answer: A
Rationale: Cystic fibrosis is an autosomal recessive disorder caused by mutations in the CFTR gene.
An infant is experiencing dyspnea related to patent ductus arteriosus (PDA). What does the nurse understand regarding why dyspnea occurs?
- A. Blood is circulated through the lungs again, causing pulmonary circulatory congestion.
- B. Blood is shunted past the pulmonary circulation, causing pulmonary hypoxia.
- C. Blood is shunted past cardiac arteries, causing myocardial hypoxia.
- D. Blood is circulated through the ductus from the pulmonary artery to the aorta, bypassing the left side of the heart.
Correct Answer: A
Rationale: When PDA is present, oxygenated blood recycles through the lungs, overburdening the pulmonary circulation.
The following contribute to the natural immunity transmitted in breast milk:
- A. Macrophages
- B. Natural killer cells
- C. Lysozyme
- D. Secretory IgA
Correct Answer: D
Rationale: Secretory IgA in breast milk plays a crucial role in providing passive immunity to the infant by protecting mucosal surfaces from pathogens.
The most common indication of heart transplantation in the neonate is
- A. Hypoplastic left heart syndrome
- B. Hypoplastic right heart syndrome
- C. Severe Ebstein's anomaly
- D. Dilated cardiomyopathy
Correct Answer: A
Rationale: Hypoplastic left heart syndrome is the most common indication for heart transplantation in neonates.