Nokea
A client has undergone a nephrectomy and is placed under observation after a urethral catheter insertion. As part of the nursing care plan, the nurse records the color of drainage from each tube and catheter. Which of the ff is the reason for this?
- A. To restore and maintain intravascular volume
- B. To provide a means for further comparison and evaluation
- C. To avoid interference with wound drainage
- D. To prevent pain related to obstruction
Correct Answer: B
Rationale: Recording the color of drainage from each tube and catheter is crucial in the nursing care plan as it provides a means for further comparison and evaluation. Changes in the color of drainage can indicate potential issues such as infection, bleeding, or other complications post-surgery. By monitoring the color of drainage, the nurse can identify any abnormal changes early on and take appropriate actions to address them promptly. This practice helps in assessing the patient's condition and ensuring optimal recovery and healing after the surgery.
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Will is being assessed by Nurse Lucas for possible intussusception; which of the following would be least likely to provide valuable information?
- A. Abdominal palpation
- B. Family history
- C. Pain pattern
- D. Stool inspection
Correct Answer: B
Rationale: When assessing a patient like Will for possible intussusception, the least likely to provide valuable information would be the family history. While family history can help identify potential genetic predispositions or conditions that may contribute to a patient's current health concerns, in this case, the focus is on Will's immediate symptoms and diagnostic indicators related to possible intussusception. Abdominal palpation, pain pattern assessment, and stool inspection are more directly relevant to evaluating Will's current condition and determining the likelihood of intussusception. Family history, while important in a broader health context, would be least likely to provide immediate insights into Will's specific situation with intussusception.
The activation of B cells in humoral immunity is assisted by which of the following?
- A. Cytotoxic T cells
- B. Suppressor T cells
- C. Helper T cells
- D. Neutrophils
Correct Answer: C
Rationale: In humoral immunity, the activation of B cells is facilitated by helper T cells. Helper T cells play a crucial role in coordinating the immune response by interacting with B cells. They secrete cytokines that stimulate B cells to proliferate and differentiate into antibody-secreting plasma cells. Without the assistance of helper T cells, the activation of B cells and the production of antibodies would be impaired. Cytotoxic T cells are involved in cell-mediated immunity, supressor T cells regulate immune response, and neutrophils are involved in phagocytosis and innate immunity, but they do not directly assist in B cell activation in humoral immunity.
Which of the ff is the effect of a decrease in the number of lymphocytes with age?
- A. Decreased resistance to infection
- B. Cognitive problems
- C. Urinary incontinence
- D. Decrease in various blood components
Correct Answer: A
Rationale: Lymphocytes are a type of white blood cell that plays a crucial role in the body's immune system by helping to fight off infections and diseases. A decrease in the number of lymphocytes with age means that the immune system may not function as effectively as it used to. This can lead to a decreased resistance to infections, making older individuals more susceptible to illnesses and diseases. Therefore, the effect of a decrease in the number of lymphocytes with age is a decreased resistance to infection.
When should the nurse expect breastfeeding-associated jaundice to first appear in a normal newborn?
- A. 0 to 12 hours
- B. 12 to 24 hours
- C. 2 to 4 days
- D. 4 to 5 days
Correct Answer: C
Rationale: Breastfeeding-associated jaundice typically first appears in a normal newborn between 2 to 4 days after birth. This type of jaundice is usually mild and is caused by insufficient milk intake, leading to decreased bilirubin elimination. It is important for healthcare providers to monitor the baby's weight and ensure adequate feeding to prevent or address breastfeeding-associated jaundice.
A 2-year-old male child has an asymptomatic right flank mass discovered incidentally by the mother while bathing. Suspicion of Wilms tumor is raised. Of the following, the LEAST likely investigation to be performed in this child is
- A. plain abdominal radiography
- B. computerized tomography (CT) scan of the abdomen
- C. CT scan of the chest
- D. biopsy of the mass
Correct Answer: D
Rationale: Biopsy is generally avoided in suspected Wilms tumor to prevent upstaging the disease.