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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Regarding cystic fibrosis:
- A. It is inherited as autosomal recessive
- B. There is increased risk of bronchial carcinoma in late adulthood
- C. Biliary cirrhosis is a recognised feature
- D. In neonates, intestinal obstruction may be the first presentation
Correct Answer: A
Rationale: Cystic fibrosis is an autosomal recessive disorder caused by mutations in the CFTR gene.
The jugular venous pressure (JVP) has a predictable relationship with pulmonary artery wedge pressure (PAWP). A JVP of >12 mm Hg predicted PAWP >22 mm Hg by 88% in which of the following trials?
- A. BNP
- B. ESCAPE
- C. EVEREST
- D. EMPA REG
Correct Answer: B
Rationale: The ESCAPE trial studied the effectiveness of therapies in patients with advanced heart failure and showed that elevated JVP was correlated with high pulmonary artery wedge pressures.
Nurse Kelly is teaching the parents of a young child how to handle poisoning. If the child ingests poison, what should the parents do first?
- A. Administer ipecac syrup
- B. Call an ambulance immediately
- C. Call the poison control center
- D. Punish the child for being bad
Correct Answer: C
Rationale: Calling the poison control center provides immediate guidance on how to handle the specific type of poisoning and whether further medical intervention is needed.
List THREE indications for intervention for aortopathy in Marfan’s syndrome in an older teenager.
- A. Aortic root or ascending aorta dilation >44-50mm
- B. Symptomatic (pain consistent with rupture)
- C. Growth of >0.5cm/y
- D. All of the above
Correct Answer: D
Rationale: These are significant indicators that require surgical intervention to prevent further complications, such as rupture or dissection.
Common causes of seizures in a neonate are:
- A. Hypocalcaemia
- B. Hypoglycaemia
- C. Pyridoxine deficiency
- D. Hydrocephalus
Correct Answer: B
Rationale: The correct answer is B because hypoglycaemia is a common cause of neonatal seizures. The other options (a, c, d, e) are also causes but less common.