Nokea
A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. What action should the nurse take first?
- A. Notify the healthcare provider
- B. Assure the client that such feelings occur with wound infections
- C. Visualize the abdominal incision
- D. Obtain sterile towels soaked in saline
Correct Answer: C
Rationale: Visualizing the incision helps determine if dehiscence or evisceration has occurred, which requires immediate intervention.
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Early features of heart failure in infancy include:
- A. Bradycardia
- B. Oedema
- C. Tachypnoea
- D. Hepatomegaly
Correct Answer: C
Rationale: Tachypnoea is an early indicator of heart failure in infants, as the body tries to compensate for reduced oxygenation by increasing the respiratory rate.
A 6-month-old presents with tachycardia, tachypnea, and poor feeding for 3 months. Physical examination reveals a continuous machinery murmur and a wide pulse pressure with a prominent apical impulse. The most likely diagnosis is
- A. pulmonic stenosis
- B. aortic stenosis
- C. ventricular septal defect
- D. patent ductus arteriosus
Correct Answer: D
Rationale: Patent ductus arteriosus causes a continuous machinery murmur and wide pulse pressure.
What does the nurse explain that a ventricular septal defect will allow?
- A. Blood to shunt left to right, causing increased pulmonary flow and no cyanosis
- B. Blood to shunt right to left, causing decreased pulmonary flow and cyanosis
- C. No shunting because of high pressure in the left ventricle
- D. Increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating volume
Correct Answer: A
Rationale: Pulmonary blood flow is increased when a ventricular septal defect exists. The blood shifts from left to right because of the higher pressure in the left ventricle. This particular shift does not cause cyanosis.
Recurrent pneumonia is defined in children as having a frequency of episodes more than or equal to
- A. 2 episodes in 6 months
- B. 2 episodes in one year
- C. 3 episodes ever without radiographic clearance
- D. 4 episodes ever with radiographic clearance
Correct Answer: A
Rationale: Recurrent pneumonia in children is defined as having 2 or more episodes in 6 months, indicating a pattern of frequent infections.
SVT
- A. HR . 220 /min
- B. Adenosine helpful in management
- C. Beat to beat variation is not present
- D. Valsalvar maneuver is a treatment method
Correct Answer: B
Rationale: Adenosine is effective in managing supraventricular tachycardia by interrupting reentrant pathways.