Nokea
24 hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for:
- A. Removal of the transplanted kidney
- B. High-dose IV cyclosporine (Sandimmune) therapy
- C. Bone marrow transplant
- D. Intra-abdominal instillation of methylprednisolone sodium succinate (Solu-Medrol)
Correct Answer: A
Rationale: Hyperacute rejection occurs immediately after transplantation, within minutes to up to 24 hours. It is a rapid and severe rejection reaction that is usually irreversible. It occurs due to pre-existing antibodies against the donor organ. In hyperacute rejection, the transplanted kidney must be removed to prevent further complications and ensure the safety of the patient. Treatment with immunosuppressive medications like cyclosporine or corticosteroids is not effective in this situation. Bone marrow transplant is not indicated in the treatment of hyperacute rejection.
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An adult has a Hickman type central venous catheter and needs to have blood drawn from it. Which of the following should the nurse do first?
- A. Use sterile technique to assemble supplies needed
- B. Aspirate and discard the first 10 ml of the blood
- C. First flush the catheter with heparinized solution, then withdraw the blood
- D. Remove the cap of the catheter and replace it with a new one
Correct Answer: C
Rationale: Before drawing blood from a central venous catheter like a Hickman type, it is essential to ensure that the catheter is patent and free of any clots. Flushing the catheter with a heparinized solution (to prevent clot formation) before withdrawing blood helps clear the catheter and ensures accurate blood sample collection. Removing clots or obstructions from the catheter is crucial to prevent complications and maintain the catheter's function. Therefore, it is important to first flush the catheter with a heparinized solution before drawing blood from it.
A nurse is teaching parents about prevention and treatment of colic. Which should the nurse include in the teaching plan?
- A. Avoid use of pacifiers.
- B. Eliminate all second-hand smoke contact.
- C. Lay infant flat after feeding.
- D. Avoid swaddling the infant.
Correct Answer: B
Rationale: Second-hand smoke exposure has been linked to an increased risk of colic in infants. Colic is a condition characterized by excessive, inconsolable crying in otherwise healthy infants. By eliminating all second-hand smoke contact, the nurse is helping to reduce potential triggers for colic and promoting a healthier environment for the infant. This is an important aspect of prevention and treatment that should be emphasized in the teaching plan for parents.
Which of the ff blood vessel is commonly affected by thrombophlebitis?
- A. Veins deep in the upper extremities
- B. Popliteal vein of the leg
- C. Veins deep in the lower extremities
- D. Veins connected to the heart
Correct Answer: C
Rationale: Thrombophlebitis commonly affects the veins deep in the lower extremities, such as the femoral vein or the iliac vein. This condition involves the formation of a blood clot (thrombus) in a vein, usually due to inflammation or injury to the vein wall. The lower extremities are more prone to thrombophlebitis because of factors like gravity, reduced blood flow in the veins of the legs, and prolonged sitting or immobility which can increase the risk of blood clot formation. Thrombophlebitis in the lower extremities can potentially lead to serious complications, such as pulmonary embolism if a clot breaks loose and travels to the lungs.
A patient is admitted to a medical unit with a diagnosis of heart failure. The patient reports that she has had increasing fatigue during the past 2 weeks. Which of the following is the most likely cause of this fatigue?
- A. Dyspnea
- B. Decreased cardiac output
- C. Dry cough
- D. Orthopnea
Correct Answer: B
Rationale: Fatigue in a patient with heart failure is commonly caused by decreased cardiac output. In heart failure, the heart is unable to pump enough blood to meet the body's demands, resulting in reduced delivery of oxygen and nutrients to the tissues. This can lead to generalized weakness and fatigue. Dyspnea (choice A) is commonly associated with heart failure but is more specific to difficulty breathing, while a dry cough (choice C) is a symptom that can be present but is not typically the primary cause of fatigue. Orthopnea (choice D) is a symptom of heart failure characterized by difficulty breathing when lying flat but is not directly related to the patient's increasing fatigue in this scenario.
A nurse is conducting a teaching session for parents of infants. The nurse explains that which behavior indicates that an infant has developed object permanence?
- A. Recognizes familiar face, such as mother
- B. Recognizes familiar object, such as bottle
- C. Actively searches for a hidden object
- D. Secures objects by pulling on a string
Correct Answer: C
Rationale: Object permanence is the understanding that objects continue to exist even when they can't be seen, heard, or touched. When an infant actively searches for a hidden object, it demonstrates that the infant has developed object permanence. This behavior implies that the infant understands that the object still exists even though it is temporarily out of sight. This usually emerges around 8-12 months of age, according to Piaget's theory of cognitive development. The other choices do not specifically relate to the concept of object permanence as directly as actively searching for a hidden object does.