Nokea
A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?
- A. Obtain oxygen saturation level
- B. Encourage incentive spirometry
- C. Assess lower extremity circulation
- D. Administer PRN oral antipyretic
Correct Answer: D
Rationale: Administering an antipyretic addresses the fever, which is a priority in this client to prevent further complications.
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Features that would increase suspicion of cerebral palsy at age 9 months include:
- A. Presence of Moro reflex
- B. Abductor spasm
- C. Hand dominance
- D. Grasp reflex
Correct Answer: C
Rationale: Hand dominance at 9 months is a red flag for cerebral palsy. The persistence of primitive reflexes like the Moro and grasp reflexes can also be indicative.
Hypoglycemia in an infant is defined as whole blood glucose level less than
- A. 40 mg/dl
- B. 50 mg/dl
- C. 60 mg/dl
- D. 80 mg/dl
Correct Answer: A
Rationale: Hypoglycemia in infants is defined as a whole blood glucose level less than 40 mg/dl, as this threshold is critical for brain function.
In Wolff-Parkinson-White syndrome:
- A. The abnormal pathway is between the atrial and ventricular myocardium
- B. Wide QRS complexes occur more frequently than narrow QRS
- C. Narrow QRS complexes are regular
- D. Verapamil is the treatment of choice for atrial fibrillation
Correct Answer: B
Rationale: In Wolff-Parkinson-White syndrome, a wide QRS complex is often seen due to the presence of an accessory pathway that bypasses the normal conduction system.
The main risk factor for developing deep vein thrombosis is:
- A. Prolonged immobility
- B. Age
- C. Obesity
- D. Family history
Correct Answer: A
Rationale: Prolonged immobility, such as during long flights or post-surgery, is a significant risk factor for developing deep vein thrombosis (DVT).
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.