Nokea
A client who is receiving chemotherapy is vomiting. Which nursing intervention should the nurse implement first?
- A. Teach the client about the importance of hydration
- B. Report the volume of emesis to the healthcare provider
- C. Administer ondansetron hydrochloride (Zofran)
- D. Encourage the client to limit the amount of movement
Correct Answer: C
Rationale: Administering ondansetron (Zofran) will help relieve the vomiting and prevent dehydration, addressing the immediate concern.
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The following are true statements:
- A. Tissue plasminogen activator is derived from endothelium
- B. Heparin acts through antithrombin III
- C. Protein C deficiency is autosomal recessive transmitted
- D. Protein C is vitamin K dependent
Correct Answer: B
Rationale: Heparin acts through antithrombin III: Heparin enhances the activity of antithrombin III, which inhibits thrombin and other clotting factors, helping prevent clot formation.
All of the following are conditions with combined cellular and antibody immunodeficiency, except
- A. Ataxia telangiectasia
- B. Reticular dysgenesis
- C. Common variable immunodeficiency
- D. Severe combined immunodeficiency
Correct Answer: C
Rationale: Common variable immunodeficiency (CVID) is primarily an antibody deficiency, not a combined immunodeficiency.
Tests used in establishing a diagnosis of coeliac disease are:
- A. IgA anti-endomysial antibodies
- B. IgM anti-reticulin antibodies
- C. IgA anti-gliadin antibodies
- D. Duodenal biopsy
Correct Answer: D
Rationale: A duodenal biopsy is the gold standard for diagnosing coeliac disease, as it provides histological confirmation of the disease.
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?
- A. Inappropriate laughter
- B. Increasing anxiety
- C. Weakened cough effort
- D. Asymmetrical weakness
Correct Answer: C
Rationale: A weakened cough effort can lead to respiratory complications, which are life-threatening in ALS patients.
The severity of symptoms of Ebstein anomaly and the degree of cyanosis are high and depend on the extent of
- A. displacement of the tricuspid valve
- B. cardiac dysrhythmias
- C. atrial right-to-left shunt
- D. pulmonary vascular resistance
Correct Answer: A
Rationale: Displacement of the tricuspid valve is a key determinant of symptom severity in Ebstein anomaly.