a newborn has a meningomyelocele; the nurse should place him in which position:
- A. semi-fowler's
- B. supine
- C. prone
- D. non of the above is correct
Correct Answer: C
Rationale: A newborn with meningomyelocele should be placed in a prone position to prevent trauma or pressure on the lesion. Placing the newborn in the prone position helps prevent the lesion from coming in contact with surfaces and reduces the risk of infection and injury. By positioning the newborn prone, gravity will assist in closing the lesion and reducing the risk of complications. It is crucial to follow this positioning guideline to ensure the infant's safety and well-being.
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The age at which the infant can achieve early head control with bobbing motion when pulled to sit is
- A. 2 months
- B. 3 months
- C. 4 months
- D. 6 months
Correct Answer: A
Rationale: Head control typically begins developing around 2 months.
A client with allergic rhinitis is prescribed loratadine (Claritin). On a follow-up visit, the client tells the nurse, "I take one 10-mg of Claritin with a glass of water two times daily". The nurse concludes that the client requires additional teaching about this medication because:
- A. Loratadine isn't available in 10mg tablets
- B. Loratadine should be taken on an empty stomach
- C. Loratadine should be taken once daily for allergenic rhinitis
- D. Claritin isn't the trade name for loratadine
Correct Answer: C
Rationale: Loratadine (Claritin) is typically taken once daily for allergic rhinitis. Taking it two times daily as stated by the client is unnecessary and indicates a lack of understanding about the appropriate dosing schedule for this medication. Claritin is indeed the trade name for loratadine, and it is available in 10mg tablets, but the issue here is the incorrect dosing frequency.
A patient has chronic respiratory acidosis related to long-standing lung disease. Which of the following problems is the cause?
- A. Hyperventilation
- B. Loss of acid by kidneys
- C. Hypoventilation
- D. Loss of base by kidneys CARING FOR CLIENTS REQUIRING INTRAVENOUS THERAPY
Correct Answer: C
Rationale: Chronic respiratory acidosis is a condition where there is an excess of carbon dioxide (CO2) in the blood due to inadequate exhalation of CO2. This typically occurs as a result of hypoventilation, which is characterized by breathing at an abnormally slow rate or shallow depth. In patients with long-standing lung disease, the ability to effectively exchange gases in the lungs is compromised, leading to a buildup of CO2 in the bloodstream and subsequent respiratory acidosis. Hyperventilation, on the other hand, would result in a decrease in CO2 levels in the blood, while the loss of acid or base by the kidneys is related to metabolic acidosis or alkalosis, not respiratory acidosis. Therefore, in this case, the primary problem causing chronic respiratory acidosis is hypoventilation.
Nurse Lina gives discharge instructions to Aling Maria, who is experiencing an exacerbation of COPD because of an upper respiratory tract infection, regarding her diet at home. Which of the following food choices would be appropriate?
- A. low fat low cholesterol
- B. low sodium diet
- C. bland soft diet
- D. high calorie high protein
Correct Answer: D
Rationale: A patient experiencing an exacerbation of COPD, especially due to an infection, requires a diet that is high in calories and protein. This is because during exacerbations, the body's energy requirements increase due to increased work of breathing and inflammation. High-calorie intake helps provide the necessary energy for breathing and healing. Additionally, a high-protein diet is important for maintaining respiratory and skeletal muscle strength, which can be affected during exacerbations of COPD. Therefore, a high-calorie high-protein diet would be most appropriate for Aling Maria to support her recovery and overall health during this period.
The following are warning signs of cancer. Which one is not?
- A. Change In bladder and bowel habits
- B. Weight gain
- C. Indigestion or difficulty in swallowing
- D. Nagging cough or hoarseness
Correct Answer: B
Rationale: Weight gain is not typically considered a warning sign of cancer. In fact, unexplained weight loss is more commonly associated with certain types of cancer. The other options all relate to symptoms that could potentially be warning signs of cancer and are worth discussing with a healthcare professional for further evaluation.