Nokea
A baby that was born 5 minutes earlier is tachypneic, tachycardic, and markedly cyanotic. A STAT echocardiogram confirms the presence of a cyanotic congenital cardiac defect. Which of the following defects would be consistent with the assessment findings?
- A. Patent ductus arteriosus
- B. Transposition of the great vessels
- C. Atrial septal defect
- D. Ventricular septal defect
Correct Answer: B
Rationale: Transposition of the great vessels is a cyanotic congenital heart defect where the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle. This results in two separate circulatory systems - one for oxygenated blood and another for deoxygenated blood. Due to this abnormal circulation, babies with transposition of the great vessels may present with severe cyanosis soon after birth. They can also develop tachypnea and tachycardia as compensatory mechanisms to maintain oxygen delivery. A STAT echocardiogram would confirm the diagnosis by showing the abnormal connection of the great vessels.
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Which of the ff suggestions should a nurse give breastfeeding mothers to prevent or eliminate mastitis and breast abscess? Choose all that apply
- A. Offer the opposite breast at each feeding to their
- B. Avoid frequent nursing of the infants
- C. Avoid breastfeeding
- D. Ensure that their hands and breasts are clean
Correct Answer: D
Rationale: Keeping hands and breasts clean is crucial in preventing infections like mastitis and breast abscess. Proper hygiene practices can help reduce the risk of introducing harmful bacteria to the breast during breastfeeding. It is essential for breastfeeding mothers to wash their hands before each feeding session and ensure that the breast is clean before nursing.
By the age of 7 months, the infant is able to do all the following EXCEPT
- A. transfer object from hand to hand
- B. actively bounces
- C. uses radial palm grasp
- D. cruises
Correct Answer: D
Rationale: Cruising typically occurs later, around 9-10 months.
A guest who is diabetic attended a bridal affair. The guest started to tremble and started to feel dizzy. Luckily a nurse is present. The best action for the nurse to take is to:
- A. encourages the guest to eat some
- B. call the guest's personal hygiene
- C. offer the guest a peppermint
- D. give the guest a glass of orange juice
Correct Answer: D
Rationale: The best action for the nurse to take in this situation is to give the guest a glass of orange juice (Choice D). The guest is most likely experiencing hypoglycemia (low blood sugar) due to diabetes. Orange juice contains natural sugars that can help raise the guest's blood sugar levels quickly. Since the guest is feeling dizzy and trembling, providing a source of fast-acting sugar like orange juice is crucial in addressing the low blood sugar and preventing the situation from worsening. It is important to follow up with a source of longer-lasting carbohydrates and protein after the guest's blood sugar levels have stabilized.
A client has been scheduled for a Schilling test. What instruction will the nurse give the client?
- A. Take nothing mouth fro 12 hours prior to the test
- B. Collect his urine for 12 hours
- C. Administer a fleet enema the evening before the test
- D. Empty his bladder immediately before the test
Correct Answer: B
Rationale: The correct instruction the nurse will give to the client scheduled for a Schilling test is to collect his urine for 12 hours. The Schilling test is a diagnostic test used to assess the body's ability to absorb vitamin B12. The test involves collecting urine samples over a period of 24 hours after the client ingests a small amount of radioactive vitamin B12. By collecting urine for 12 hours, the healthcare provider will be able to analyze the excretion of the vitamin and determine the client's ability to absorb vitamin B12. Instructions such as fasting, enema administration, or emptying the bladder before the test are not typically associated with the Schilling test procedure.
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care?
- A. Administering aspirin if the temperature exceeds 102â—‹1 F (38.8â—‹0 C)
- B. inspecting the skin for petechiae once every shift
- C. providing for frequent rest periods
- D. Placing the client in strict isolation
Correct Answer: C
Rationale: Providing for frequent rest periods is the most appropriate intervention for a client newly diagnosed with radiation-induced thrombocytopenia. Thrombocytopenia is characterized by a decreased number of platelets, which are essential for blood clotting. Clients with thrombocytopenia are at an increased risk for bleeding and bruising. Therefore, it is important to prevent activities that may lead to injury or bleeding. Providing frequent rest periods allows the client to conserve energy and minimize the risk of trauma that could lead to bleeding complications. This intervention helps manage the symptoms associated with thrombocytopenia and promotes the client's safety and well-being.