Nokea
A nurse is assessing a patient admitted for an asthma exacerbation. Which breath sounds does the nurse expect to assess?
- A. Rubs
- B. Rattles
- C. Wheezes
- D. Crackles
Correct Answer: C
Rationale: Wheezes are high-pitched, musical sounds heard during inspiration or expiration due to the constriction or narrowing of the airways, commonly associated with asthma exacerbations. The presence of wheezes indicates airway obstruction, making it the expected breath sound in a patient admitted for an asthma exacerbation. Rubs, rattles, and crackles are associated with different conditions such as pleural friction rubs, respiratory secretions, and fluid in the alveoli, respectively.
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When a patient participates in a research study, the pediatric nurse's primary concern is to ensure that the:
- A. parent or guardian has given verbal consent for the patient's participation.
- B. quality of care that the patient receives will not be affected if the patient chooses to withdraw from the study.
- C. research meets the developmental needs of the patient.
- D. research will directly benefit the patient.
Correct Answer: B
Rationale: Ensuring that the quality of care remains unaffected regardless of the patient's participation status is paramount to ethical research practices.
A nurse is directed to administer a hypotonic intravenous solution. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms except:
- A. O.45% sodium chloride
- B. 5% dextrose in water
- C. O.90% sodium chloride
- D. 5% dextrose in normal saline solution
Correct Answer: C
Rationale: Hypotonic solutions have lower osmolarity compared to the intracellular fluid, causing water to move into the cells by osmosis. This can lead to further swelling of the cells in the body. In the case of hypovolemia, the body is already experiencing a deficit of fluid and electrolytes, so administering a hypotonic solution like 0.90% sodium chloride would further exacerbate cellular swelling and potentially lead to cellular damage. Therefore, using 0.90% sodium chloride as a compensatory mechanism for hypovolemia would not be appropriate.
Which of the following is the most common cause of hyperaldosteronism?
- A. Excessive sodium intake
- B. Deficient potassium intake
- C. A pituitary adenoma
- D. An adrenal adenoma
Correct Answer: D
Rationale: The most common cause of hyperaldosteronism is an adrenal adenoma, which is a benign tumor of the adrenal gland. Adrenal adenomas produce excessive amounts of aldosterone, a hormone that regulates sodium and potassium balance in the body. This overproduction of aldosterone can lead to increased sodium retention and potassium excretion, resulting in hypertension and low potassium levels in the blood. Excessive sodium intake and deficient potassium intake are not common causes of hyperaldosteronism. Pituitary adenomas are associated with conditions such as Cushing's syndrome or acromegaly, but not hyperaldosteronism.
Which white blood cells are involved in releasing histamine during an allergic reaction?
- A. Basophils
- B. Monocytes
- C. Eosinophils
- D. Neutrophils
Correct Answer: A
Rationale: Basophils are a type of white blood cell that are involved in releasing histamine during an allergic reaction. When an allergen triggers the immune system, basophils release histamine and other chemical mediators. Histamine plays a key role in the inflammatory response associated with allergies, leading to symptoms such as itching, hives, and swelling. Basophils are known for their role in allergic reactions and are an important part of the body's defense against parasites and in the inflammatory response.
Samantha, age 5 years, tells the nurse that she "needs a Band-Aid" where she had an injection. Which is the best nursing action?
- A. Apply a Band-Aid.
- B. Ask her why she wants a Band-Aid.
- C. Explain why a Band-Aid is not needed.
- D. Show her that the bleeding has already stopped.
Correct Answer: C
Rationale: The best nursing action in this scenario is to explain why a Band-Aid is not needed. At 5 years old, Samantha is at an age where she can begin to understand explanations. By providing her with a simple and clear explanation, the nurse can help Samantha understand that a Band-Aid is not necessary in this situation. This also promotes education and helps Samantha learn about wound healing and appropriate care. It is important to involve the child in the decision-making process and provide education to foster their understanding of their own health.