Nokea
A nurse assesses a client who is recovering from a myocardial infarction. The client’s pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first?
- A. Compare the results with previous pulmonary artery pressure readings.
- B. Increase the intravenous fluid rate because these readings are low.
- C. Immediately notify the health care provider of the elevated pressures.
- D. Document the finding in the client’s chart as the only action.
Correct Answer: A
Rationale: Comparing the current pulmonary artery pressure readings with previous ones helps determine if the values are stable or changing, which guides further intervention.
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Recognised causes of stroke in children include:
- A. Sickle cell disease
- B. Cystinuria
- C. SLE
- D. Left-to-right shunts
Correct Answer: A
Rationale: Sickle cell disease can cause stroke in children due to the sickled cells blocking blood flow to the brain.
What are FIVE indications for surgical intervention in infective endocarditis?
- A. Heart block
- B. Abscess
- C. Valve dysfunction causing heart failure
- D. Large mobile vegetation
Correct Answer: A
Rationale: These are typical indications for surgery when complications of infective endocarditis progress to life-threatening stages.
The causes of elevated maternal serum AFP are:
- A. Trisomy 21
- B. Exomphalos
- C. Marfan syndrome
- D. Meningomyelocele
Correct Answer: D
Rationale: Elevated maternal serum alpha-fetoprotein (AFP) is associated with neural tube defects such as meningomyelocele, due to leakage of AFP into the amniotic fluid.
A fair-skinned female client who is an avid runner is diagnosed with malignant melanoma, located on the lateral surface of the lower leg. After wide margin resection, the nurse provides discharge teaching. It is most important for the nurse to emphasize the need to observe for changes in which characteristic?
- A. Elasticity of the skin
- B. Appearance of any moles
- C. Muscle aches and pains
- D. Pigmentation of the skin
Correct Answer: B
Rationale: Monitoring for changes in moles is critical for early detection of new or recurrent melanoma, which is essential for timely intervention.
Which among the following is not an admixture lesion?
- A. Transposition of great arteries
- B. Truncus arteriosus
- C. Total anomalous pulmonary venous connection
- D. Pulmonary atresia with intact ventricular septum
Correct Answer: D
Rationale: Pulmonary atresia with intact ventricular septum is not an admixture lesion.