Nokea
A client agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient?
- A. Blood relationship
- B. Compatible blood and tissue types
- C. Sex and size
- D. Need
Correct Answer: B
Rationale: The correct answer is B: Compatible blood and tissue types. This is crucial to minimize the risk of rejection and ensure a successful transplant. Matching blood and tissue types help prevent the recipient's immune system from attacking the new organ. Blood relationship (A) is not as important as compatibility. Sex and size (C) are important considerations for certain transplants but not the most crucial factor. Need (D) is relevant but does not outweigh the importance of compatibility to ensure a successful transplant.
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The nurse is aware that the shift of body fluids associated with the intravenous administration of albumin occurs by the process of:
- A. Filtration
- B. Osmosis
- C. Diffusion
- D. Active Transport
Correct Answer: A
Rationale: The correct answer is A: Filtration. Albumin is a large protein molecule that cannot pass through the semipermeable membrane of blood vessels. Therefore, the shift of body fluids associated with intravenous albumin administration occurs through the process of filtration, where fluid moves across the membrane due to a pressure difference. Osmosis (B) involves the movement of water across a semipermeable membrane, which is not the case for albumin. Diffusion (C) is the movement of molecules from an area of high concentration to low concentration, which is not how albumin moves. Active transport (D) requires energy to move substances against a concentration gradient, which is not the mechanism for albumin movement in the body.
A client comes to the clinic complaining of weight loss, fatigue, and a low-grade fever. Physical examination reveals a slight enlargement of the cervical lymph nodes. To assess possible causes for the fever, it would be most appropriate for the nurse to initially ask: a."Have you bee sexually active lately?" b, "Do you have a sore throat at the present time?"
- A. "Have you been exposed recently to anyone with an infection?"
- B. "When did you first notice that your temperature had gone up?"
Correct Answer: A
Rationale: Rationale:
- The correct answer is A, "Have you been exposed recently to anyone with an infection?" because it helps assess potential sources of infection causing the low-grade fever and other symptoms.
- Choice B is irrelevant as the client's current sore throat is not the main concern.
- Choice C and D do not address the potential infectious etiology of the symptoms.
- Overall, assessing recent exposure to infections is crucial in identifying possible sources of the client's symptoms.
What deficits would the nurse expect in a right-handed person experiencing a stroke affecting the left side of the cortex?
- A. Expressive aphasia and paralysis on the right side of the body.
- B. Expressive aphasia and paralysis on the left side of the body. .
- C. Dysarthria and paralysis on the right side of the body.
- D. Mixed aphasia and paralysis on the right side of the body.
Correct Answer: A
Rationale: The correct answer is A: Expressive aphasia and paralysis on the right side of the body. In a right-handed person, the left side of the brain controls language and right-sided motor function. A stroke affecting the left side of the cortex would lead to expressive aphasia due to damage to Broca's area, causing difficulty in speaking and forming words. Paralysis on the right side of the body would result from damage to the motor cortex in the left hemisphere. Choices B, C, and D are incorrect because they do not align with the typical deficits seen in a person with a stroke affecting the left side of the cortex in a right-handed individual.
Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients?
- A. Assessment data should be collected continuously.
- B. Assess your client after receiving the nursing report and again before giving a report to the next shift.
- C. Assess your client at least hourly if vital signs are unstable, and every two hours if stable.
- D. Assessment data should be collected prior to the physician rounding on the unit.
Correct Answer: A
Rationale: The correct answer is A because assessment data should be collected continuously to ensure timely detection of any changes in the client's condition. This allows for prompt interventions and prevents complications. Choice B is incorrect as assessment should be ongoing and not limited to specific times. Choice C is incorrect as the frequency of assessment should be based on client needs, not a fixed schedule. Choice D is incorrect as assessments should not be limited to certain times but should be ongoing to provide comprehensive care.
Which of the following questions or statements would be an appropriate termination of the health history interview?
- A. “Well, I can’t think of anything else to ask you right now.”
- B. “Can you think of anything else you would like to tell me?”
- C. “I wish you could have remembered more about your illness.”
- D. “Perhaps we can talk again sometime. Goodbye.”
Correct Answer: B
Rationale: The correct answer is B because it encourages the patient to share any additional information they may have forgotten or overlooked, ensuring a thorough health history interview. Choice A is incorrect as it implies the interviewer is unprepared or disinterested. Choice C is inappropriate as it may make the patient feel guilty or inadequate. Choice D is incorrect as it does not address the possibility of gathering more relevant information from the patient.