Nokea
A 15-month-old toddler was able to do all the following EXCEPT
- A. walks alone
- B. makes tower of 3 cubes
- C. inserts raisin in a bottle
- D. responds to his/her name
Correct Answer: D
Rationale: Responding to name usually occurs earlier, around 6-9 months.
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An elderly patient, Mr. Cruz is being cared for by nurse Bennie because of pulmonary embolism. Nurse Bennie would anticipate an order for immediate administration of:
- A. warfarin
- B. heparin
- C. dexamethazone
- D. protamine sulfate
Correct Answer: B
Rationale: In the scenario of an elderly patient like Mr. Cruz with suspected pulmonary embolism, the nurse would anticipate an order for the immediate administration of heparin. Heparin is an anticoagulant medication that works quickly to prevent the further development of blood clots. It is often used as the initial treatment for pulmonary embolism to prevent existing blood clots from getting larger and reduce the risk of new clots forming. Heparin is preferred over warfarin initially because it has a more rapid onset of action. Warfarin, which is a commonly used anticoagulant for longer-term management, takes several days to reach its full effect and requires monitoring of the prothrombin time (INR). Therefore, in Mr. Cruz's acute situation, heparin would be the most appropriate choice for immediate intervention to address the pulmonary embolism.
The nurse, in assessing the adequacy of a client's fluid replacement during the first 2 to 3 days following full- thickness burns to the trunk and right thigh, would be aware that the most significant data would be obtained from recording
- A. Weights every day .
- B. Blood pressure every 15 minutes
- C. Urinary output every hour
- D. Extent of peripheral edema every 4 hours
Correct Answer: C
Rationale: Monitoring urinary output every hour is crucial in assessing the adequacy of fluid replacement in a client with full-thickness burns. Burn injuries can result in a significant loss of fluid and electrolytes due to increased capillary permeability and excessive fluid shift from the intravascular space to the interstitial space. Adequate fluid replacement is essential to maintain tissue perfusion, prevent hypovolemia, and support organ function. By closely monitoring the urinary output every hour, the nurse can assess renal perfusion, fluid balance, and the effectiveness of fluid resuscitation. A decrease in urinary output can indicate inadequate fluid replacement, while an increase may suggest fluid overload. This information is important in guiding adjustments to the fluid replacement therapy to ensure optimal outcomes for the client. Weights, blood pressure measurements, and assessment of peripheral edema are also important data to monitor in a burn client, but urinary output is the most significant indicator of fluid balance in
Which of the ff points should a nurse include in the teaching plan for clients who have potential for hypovolemia?
- A. Avoid alcohol and caffeine
- B. Increase intake of milk and dairy products
- C. Increase intake of dried peas and beans
- D. Avoid table salt or food containing sodium
Correct Answer: A
Rationale: Clients at risk for hypovolemia, which is a condition characterized by low blood volume, should be advised to avoid alcohol and caffeine. Alcohol and caffeine are known to have diuretic effects, which can further deplete the body's fluid volume and worsen the condition. By avoiding alcohol and caffeine, clients can help maintain adequate fluid levels in the body and reduce the risk of exacerbating hypovolemia. Additionally, it is important for clients at risk for hypovolemia to stay hydrated by consuming adequate amounts of water or other hydrating fluids.
Which term refers to a newborn born before completion of week 37 of gestation, regardless of birth weight?
- A. Postterm
- B. Preterm
- C. Low birth weight
- D. Small for gestational age
Correct Answer: B
Rationale: The term "preterm" refers to a newborn born before completion of week 37 of gestation, regardless of birth weight. Preterm birth can lead to various health issues for the newborn, as they may not have fully developed before being born. It is important for healthcare providers to closely monitor preterm infants to ensure they receive the proper care and support for their development.
The MOST common cause of obstructive sleep apnea in children is
- A. obesity
- B. allergies
- C. adenotonsillar hypertrophy
- D. pharyngeal reactive edema due to gastroesophageal reflux
Correct Answer: C
Rationale: Adenotonsillar hypertrophy is the leading cause of obstructive sleep apnea in children.