Nokea
A client with draining skin lesions of the lower extremity is admitted with possible Methicillin-Resistant Staphylococcus Aureus (MRSA). Which nursing interventions should the nurse include in the plan of care?
- A. Institute contact precautions for staff and visitors.
- B. Send wound drainage for culture and sensitivity.
- C. Monitor the client's white blood cell count.
- D. Administer broad-spectrum antibiotics before obtaining cultures.
Correct Answer: B
Rationale: MRSA requires contact precautions to prevent spread, culture and sensitivity testing is necessary to identify the specific organism, and WBC count should be monitored to assess for infection.
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Patients who have undergone surgery entailing the use of cardiopulmonary bypass should be watched carefully for
- A. epilepsy disabilities
- B. learning disabilities
- C. anemia
- D. arrhythmias
Correct Answer: D
Rationale: Arrhythmias are a common complication after cardiopulmonary bypass surgery.
Patients with a small PDA have the following criteria EXCEPT
- A. asymptomatic risk for endocarditis
- B. normal peripheral pulses
- C. normal pulmonary artery pressure
- D. normal life expectancy
Correct Answer: A
Rationale: Small PDAs typically have a low risk for endocarditis.
Pulmonary hypertension is a complication of:
- A. ASD
- B. Eisenmenger syndrome
- C. Tricuspid atresia
- D. Tricuspid regurgitation
Correct Answer: B
Rationale: Eisenmenger syndrome is a well-known cause of pulmonary hypertension. The other options (a-d) can also lead to pulmonary hypertension but are less specific.
On assessment of a child admitted with a diagnosis of Kawasaki Disease, the nurse expects to note which clinical manifestation of the acute phase of the disease?
- A. Cracked lips
- B. Normal appearance
- C. Conjuntival hyperemia
- D. Desquamation of the skin
Correct Answer: C
Rationale: Conjunctival hyperemia is a common clinical manifestation during the acute phase of Kawasaki Disease, characterized by redness of the eyes without discharge.
Maltese crosses' are identified in the urinary sediments in
- A. Niemann Pick disease
- B. Gaucher disease
- C. Krabbe's disease
- D. Fabry disease
Correct Answer: D
Rationale: Fabry disease is characterized by the presence of 'Maltese crosses' in urinary sediments due to glycosphingolipid accumulation.