Nokea
A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider.
- A. Belching
- B. Amber urine
- C. Yellow sclera
- D. Flatulence
Correct Answer: C
Rationale: Yellow sclera indicates jaundice, which is a sign of bile duct obstruction and requires immediate medical attention.
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ECG
- A. Bifid P waves in large VSD
- B. Complete Ht block in cyanotic attacks of fallots
- C. RBBB in Ebstein anomaly
- D. Right axis deviation in tricuspid atresia
Correct Answer: C
Rationale: In Ebstein's anomaly, right bundle branch block (RBBB) is commonly seen on ECG.
In scabies:
- A. Itching is due to sensitisation by the mite
- B. Vesicles may be seen in children
- C. The organism is easily demonstrated
- D. Spread can occur through clothes and bedding
Correct Answer: A
Rationale: Itching in scabies is due to an allergic reaction to the mites and their products, leading to sensitization.
While assessing a newborn with respiratory distress, the nurse auscultates a machine-like heart murmur. Other findings are a wide pulse pressure, periods of apnea, increased PaCO2, and decreased PO2. The nurse suspects that the newborn has:
- A. Pulmonary hypertension
- B. Patent ductus arteriosus (PDA)
- C. Ventricular septal defect (VSD)
- D. Bronchopulmonary dysplasia
Correct Answer: B
Rationale: A machine-like murmur is the hallmark of a PDA.
The nurse is assessing a client who has tinea pedis. Which question will allow the nurse to gather further information about this condition?
- A. Do you see any improvement when using tolnaftate?
- B. Have you been avoiding wearing tight-fitting shoes?
- C. Are you experiencing pain or itching in your feet?
- D. How often do you wash your feet and change socks?
Correct Answer: A
Rationale: Tolnaftate is an antifungal medication. Asking about its effectiveness helps assess the client's treatment response and adherence.
Indications for an exchange transfusion include:
- A. ABO incompatibility
- B. Acute chest syndrome
- C. Sepsis
- D. Polycythaemia
Correct Answer: A
Rationale: Exchange transfusion is indicated in conditions like ABO incompatibility to prevent severe hemolytic disease in newborns. Acute chest syndrome sepsis polycythaemia and sickle nephropathy are not typical indications for exchange transfusion.