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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A 3-year-old child with a fever and sore throat is most likely to have:
- A. Coxsackievirus infection
- B. Tonsillitis
- C. Scarlet fever
- D. Measles
Correct Answer: B
Rationale: Tonsillitis is a common cause of fever and sore throat in young children and may be viral or bacterial in origin.
Respiratory distress at birth is mostly caused by:
- A. Diaphragmatic hernia
- B. Meconium aspiration
- C. RDS (respiratory distress syndrome)
- D. Pulmonary hypertension
Correct Answer: C
Rationale: The correct answer is C because RDS is the most common cause of respiratory distress in newborns. The other options (a, b, d, e) are less common causes.
José is a 4-year-old child scheduled for a cardiac catheterization. What should be included in preoperative teaching?
- A. Directed at his parents because he is too young to understand
- B. Detailed in regard to the actual procedures so he will know what to expect
- C. Done several days before the procedure so that he will be prepared
- D. Adapted to his level of development so that he can understand
Correct Answer: D
Rationale: Preoperative teaching should always be directed at the child’s stage of development. The caregivers also benefit from the same explanations. The parents may ask additional questions, which should be answered, but the child needs to receive the information based on developmental level. Preschoolers will not understand in-depth descriptions and should be prepared close to the time of the cardiac catheterization.
Appropriate initial management steps in an acute anaphylactic reaction to a blood transfusion include:
- A. Nebulised steroids
- B. Oxygen
- C. Intravenous hydrocortisone
- D. Intravenous anti-H2 agent
Correct Answer: B
Rationale: Oxygen is a critical initial management step in anaphylaxis to ensure adequate oxygenation during the acute phase.
A male client with diabetes mellitus (DM) is transferred from the hospital to a rehabilitation facility following treatment for a stroke with resulting right hemiplegia. He tells the nurse that his feet are always uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement.
- A. Provide a warming pad (Aqua-pad or K-pad) to feet
- B. Medicate the client with a prescribed sedative
- C. Use a bed cradle to hold the covers off the feet
- D. Place warm blankets next to the client's feet
Correct Answer: D
Rationale: Warm blankets can help improve circulation and provide comfort without the risk of burns associated with heating pads.