Nokea
A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client plan of care?
- A. Continuous cardiac monitoring
- B. Perform passive range of motion
- C. Evaluate level of consciousness
- D. Assess lung sounds q4 hours.
Correct Answer: A
Rationale: Electrical injuries can cause cardiac arrhythmias, so continuous cardiac monitoring is critical to detect and manage any life-threatening complications.
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The lower limit of pulse rate in neonate at rest is
- A. 50/min
- B. 60/min
- C. 70/min
- D. 80/min
Correct Answer: B
Rationale: The lower limit of normal pulse rate in neonates at rest is typically around 60 beats/min.
Acute bronchiolitis is associated with:
- A. A higher incidence in infants than in school children
- B. The production of copious amounts of purulent sputum
- C. Widespread fine crackles
- D. A polymorphonuclear leucocytosis
Correct Answer: A
Rationale: Acute bronchiolitis is more common in infants and is associated with fine crackles. Purulent sputum and polymorphonuclear leucocytosis are not typical features.
Hemodynamic definition of 'Isolated post-capillary Pulmonary Hypertension' is
- A. Pulmonary artery wedge pressure > 15 mm Hg
- B. Right ventricular systolic pressure > 36 mm Hg
- C. Diastolic pressure gradient < 7 mm Hg
- D. Pulmonary vascular resistance > 3 Wood units
Correct Answer: A
Rationale: Isolated post-capillary pulmonary hypertension is defined by a pulmonary artery wedge pressure greater than 15 mm Hg.
A 4-year-old child presents to the clinic with a history of persistent dry cough and wheezing. What is the nurse’s primary concern?
- A. Allergic reaction
- B. Asthma exacerbation
- C. Respiratory infection
- D. Acute bronchiolitis
Correct Answer: B
Rationale: Wheezing and persistent dry cough are hallmark symptoms of asthma exacerbation, which is the nurse's primary concern.
It is reasonable to suspect child abuse in the following situations:
- A. 6-month old with a large scalp bruise
- B. 7-year-old girl who is found masturbating
- C. 2-year old with multiple bruises of different ages over the shins
- D. 3-month old with failure to thrive
Correct Answer: A
Rationale: The correct answer is A because a large scalp bruise in a 6-month-old is highly suspicious for abuse. The other options (b-e) are less indicative of abuse.