Nokea
A male client complains of pain in his right calf, and the nurse determines that his calf is edematous and deep red. What intervention has the highest priority?
- A. Tell the client to remain in bed
- B. Apply warm compresses to the affected leg.
- C. Administer pain medication as prescribed.
- D. Encourage the client to elevate the affected leg.
Correct Answer: A
Rationale: The symptoms suggest deep vein thrombosis (DVT). Bed rest prevents dislodgment of the clot, reducing the risk of pulmonary embolism.
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In normal neonates:
- A. Extracellular fluid volume exceeds intracellular fluid volume
- B. In a term baby, plasma calcium levels exceed that of the mother
- C. Clamping the umbilical cord after cessation of cord pulsations increases the blood volume by 20% in the baby
- D. There are two arteries and one vein in the umbilical cord
Correct Answer: A
Rationale: In neonates, extracellular fluid volume is greater than intracellular fluid volume, reflecting the transition from intrauterine to extrauterine life.
The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the nurse instruct the client to maintain?
- A. left lateral
- B. Supine, knees flexed
- C. Dorsal recumbent
- D. Knee-chest
Correct Answer: A
Rationale: The left lateral position promotes drainage of the abscess and improves ventilation.
A 2-year-old child should be able to:
- A. Name three colours correctly
- B. Use plurals
- C. Build a tower of five blocks
- D. Kick a ball on request
Correct Answer: C
Rationale: A 2-year-old can typically build a tower of five blocks. Naming colors and using plurals are more advanced skills, and kicking a ball is variable.
Examples of encapsulated organisms are all except:
- A. Pseudomonas
- B. Proteus
- C. Pneumococci
- D. Salmonella
Correct Answer: A
Rationale: The correct answer is A because Pseudomonas is not an encapsulated organism. The other options (b-e) are encapsulated.
SVT in children differ from physiologic sinus tachycardia by all the following EXCEPT
- A. sudden onset and termination
- B. persistent ventricular rate of >180 bpm
- C. fixed RR interval on ECG
- D. evident change in heart rate with activity
Correct Answer: D
Rationale: Physiologic sinus tachycardia can show changes in heart rate with activity, unlike SVT which has a fixed rate.