Nokea
A baby is born temporarily immune to the diseases to which the mother is immune. The nurse understands that this is an example of which of the following types of immunity?
- A. Naturally acquired passive immunity
- B. Naturally acquired active immunity
- C. Artificially acquired passive immunity
- D. Artificially acquired active immunity
Correct Answer: A
Rationale: The correct answer is A: Naturally acquired passive immunity. This type of immunity occurs when antibodies are passed from mother to baby through the placenta or breast milk, providing temporary protection. The baby does not produce its antibodies, hence it is passive. Choice B, naturally acquired active immunity, involves the body producing its antibodies after exposure to a pathogen. Choice C, artificially acquired passive immunity, involves receiving preformed antibodies from an external source. Choice D, artificially acquired active immunity, involves the body producing antibodies in response to vaccination.
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Mr Santos is placed on seizure precaution. Which of the following would be contraindicated?
- A. Obtain his oral temperature
- B. Allow him to wear his own clothing
- C. Encourage to perform his own personal
- D. Encourage him to be out of bed hygiene
Correct Answer: A
Rationale: The correct answer is A: Obtain his oral temperature. Seizure precautions typically include avoiding putting objects in the mouth to prevent injury during a seizure. Taking an oral temperature involves placing an object in the mouth, which could pose a risk if a seizure occurs. Choices B, C, and D are not contraindicated as they do not directly involve potential risks during a seizure. Allowing the patient to wear his own clothing, encouraging personal hygiene, and promoting mobility are safe practices that do not increase the risk of harm during a seizure.
A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse’s initial action in response to these observations?
- A. Proceed to the next patient’s room to make rounds.
- B. Determine the patient does not want any pain medicine.
- C. Ask the patient about the facial grimacing with movement.
- D. Administer the pain medication ordered for moderate to severe pain.
Correct Answer: C
Rationale: The correct answer is C: Ask the patient about the facial grimacing with movement. This is the initial action because the discrepancy between the patient's verbal pain level and non-verbal cues needs clarification. By directly asking the patient about the facial grimacing, the nurse can gather more information to assess the actual pain level accurately. This step ensures a comprehensive understanding of the patient's pain experience and guides further interventions.
Incorrect choices:
A: Proceed to the next patient’s room to make rounds - This choice neglects the need to address the discrepancy in the patient's pain assessment.
B: Determine the patient does not want any pain medicine - Assuming the patient's preference without further assessment can lead to inadequate pain management.
D: Administer the pain medication ordered for moderate to severe pain - Without clarifying the reason behind the facial grimacing, administering pain medication may not be appropriate and could result in unnecessary medication use.
Deaths have occurred when potassium chloride has been used incorrectly to flush a lock or central venous catheter. Which of the ff precautions should a nurse take to minimize this risk?
- A. Use a dilute form of potassium chloride before flushing locks
- B. Warm the KCL before flushing locks
- C. Read labels carefully on vials containing flush solutions for locks
- D. Replace the existing locks with new ones to avoid flushing
Correct Answer: C
Rationale: Step 1: Reading labels carefully on vials containing flush solutions for locks is crucial to ensure the correct solution is being used.
Step 2: Potassium chloride should not be used to flush locks as it can be fatal if administered incorrectly.
Step 3: By carefully reading labels, the nurse can verify that the correct solution is being used, thus minimizing the risk of using potassium chloride.
Summary:
- Choice A is incorrect as using a dilute form of potassium chloride does not address the issue of incorrect administration.
- Choice B is incorrect as warming the solution does not prevent the risk associated with using potassium chloride.
- Choice D is incorrect as replacing locks does not address the root cause of the issue, which is improper administration.
After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer?
- A. Esophageal carcinoma
- B. Laryngeal carcinoma
- C. Pituitary carcinoma
- D. Colorectal carcinoma
Correct Answer: C
Rationale: Rationale:
1. Transsphenoidal adenohypophysectomy is the surgical removal of the pituitary gland's adenohypophysis.
2. The procedure is used to treat pituitary tumors, which can be benign or malignant, but commonly referred to as pituitary adenomas.
3. Pituitary adenomas may secrete hormones excessively, leading to various endocrine disorders.
4. Hormone replacement therapy is required post-surgery to manage hormonal deficiencies.
5. Therefore, the correct answer is C (Pituitary carcinoma).
Summary:
A, B, and D are incorrect as they do not involve the pituitary gland, which is the primary target of a transsphenoidal adenohypophysectomy.
Which of the following would the nurse evaluate as laboratory data that support the occurrence of AIDS?
- A. 900 CD 4+ cells
- B. 500 CD 4+ cells
- C. 700 CD 4+ cells
- D. 200 CD 4+ cells
Correct Answer: D
Rationale: The correct answer is D: 200 CD4+ cells. In AIDS, the immune system is severely compromised, leading to a decrease in CD4+ T cells. A CD4+ count below 200 cells/mm3 is a key indicator of AIDS, as it signifies advanced immunodeficiency. Choices A, B, and C all have CD4+ cell counts above 200, which would not support the occurrence of AIDS. Therefore, the nurse would evaluate a CD4+ count of 200 cells as laboratory data that support the occurrence of AIDS.