Nokea
A client is undergoing test for multiple myeloma. Diagnostic study findings in multiple Myeloma includes:
- A. A decreased serum creatinine level.
- B. Bence jones protein in the urine.
- C. Hypocalcemia.
- D. A low serum protein level.
Correct Answer: B
Rationale: Diagnostic study findings in multiple myeloma often include the presence of Bence Jones protein in the urine. Bence Jones protein is a type of abnormal protein (immunoglobulin light chain) produced by the abnormal plasma cells in multiple myeloma. Its presence in the urine can be detected through urine protein electrophoresis and is a characteristic feature of the disease. Other common findings in multiple myeloma include hypercalcemia, elevated serum creatinine level, and high serum protein level due to the excess production of monoclonal immunoglobulins.
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The nurse recognizes that the major early problem for Mr. Gabatan will be:
- A. Bladder control
- B. Quadriceps setting
- C. Client education
- D. Use of aids for ambulation
Correct Answer: B
Rationale: The major early problem for Mr. Gabatan will likely be quadriceps setting. Quadriceps setting exercises are important for preventing muscle weakness and atrophy, especially after surgery or prolonged immobility. Strengthening the quadriceps muscles is essential for maintaining proper knee function, stability, and overall mobility. It is a crucial aspect of early rehabilitation and recovery for patients, particularly after orthopedic procedures such as joint replacements or fractures. Maintaining and improving quadriceps strength will also play a significant role in promoting Mr. Gabatan's independence and mobility during his recovery process.
Wilma is using a portable suction unit at home, What is the amount of suction required by James using this unit?
- A. 2-5 mmHg
- B. 10-15 mmHg
- C. 5-10 mmHg
- D. 20-25 mmHg
Correct Answer: A
Rationale: The amount of suction typically required for routine suctioning for adults using a portable suction unit at home is 80-120 mmHg for an adult patient. However, for children or individuals with sensitive airways, the recommended amount of suction is lower, ranging from 2-5 mmHg. Since the question mentions that James is using the unit at home, it is safer to assume that a lower amount of suction (2-5 mmHg) would be appropriate for his needs.
When should the nurse expect jaundice to be present in a newborn with hemolytic disease?
- A. At birth
- B. During first 24 hours after birth
- C. 24 to 48 hours after birth
- D. 48 to 72 hours after birth
Correct Answer: D
Rationale: In a newborn with hemolytic disease, jaundice typically appears 48 to 72 hours after birth due to the accumulation of bilirubin in the baby's blood. This condition is known as hyperbilirubinemia, which occurs when the liver is still immature and unable to effectively process bilirubin. The breakdown of red blood cells in hemolytic disease leads to an increased production of bilirubin, resulting in jaundice. It is important for healthcare providers to monitor the newborn closely during this time period to ensure appropriate management of the jaundice.
The nurse is taking care of a 2-year-old child with a macule skin lesion. Which clinical finding should the nurse expect to assess with this type of lesion?
- A. Flat, nonpalpable, and irregularly shaped lesion that is greater than 1 cm in diameter
- B. Heaped-up keratinized cells, flaky exfoliation, irregular, thick or thin, dry or oily, varied in size
- C. Flat, brown mole less than 1 cm in diameter
- D. Elevated, flat-topped, firm, rough, superficial papule greater than 1 cm in diameter
Correct Answer: A
Rationale: A macule is a flat, nonpalpable, and discolored area on the skin that is less than 1 cm in diameter. This type of skin lesion is typically characterized by a change in color without any change in texture or thickness of the skin. The clinical finding associated with a macule is a flat, nonpalpable lesion that is smaller in size (less than 1 cm) and regularly shaped. Therefore, the nurse should expect to assess a flat, nonpalpable, and irregularly shaped lesion that is greater than 1 cm in diameter with a different type of skin lesion, not a macule.
Five girls were victims of wasp and bee bites. Emergency treatment for these includes:
- A. A poultice of sodium bicarbonate and water may give relief
- B. A weak solution of household ammonia also decreases pain and is safe to use
- C. A and B are correct
- D. None of these
Correct Answer: D
Rationale: For emergency treatment of wasp and bee bites, it is essential to follow evidence-based guidelines. The options provided, using a poultice of sodium bicarbonate and water or a weak solution of household ammonia, are not considered effective or safe treatments for wasp and bee stings. The recommended first aid treatment for wasp and bee stings includes: