Nokea
A nurse is teaching nursing students the physiology of congenital heart defects. Which defect results in decreased pulmonary blood flow?
- A. Atrial septal defect
- B. Tetralogy of Fallot
- C. Ventricular septal defect
- D. Patent ductus arteriosus
Correct Answer: B
Rationale: Tetralogy of Fallot is a congenital heart defect characterized by four abnormalities - pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. The pulmonary stenosis in Tetralogy of Fallot results in decreased pulmonary blood flow, leading to cyanosis. The other choices (Atrial septal defect, Ventricular septal defect, Patent ductus arteriosus) do not result in decreased pulmonary blood flow.
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Which organ(s) is/are most at risk for dysfunction in a patient with a potassium level of 6.3 mEq/L?
- A. Lungs
- B. Liver
- C. Kidneys
- D. Heart
Correct Answer: D
Rationale: A potassium level of 6.3 mEq/L indicates hyperkalemia, which can have significant effects on the heart. The heart is one of the most sensitive organs to changes in potassium levels. In hyperkalemia, elevated serum potassium levels can lead to various cardiac manifestations, including dysrhythmias, conduction abnormalities, and eventually cardiac arrest. Monitoring and managing potassium levels are crucial in preventing life-threatening cardiac complications in patients with hyperkalemia. While the kidneys and other organs can also be affected by high potassium levels, the heart is the most critical organ to consider in this scenario.
Nursing intervention during the lumbar puncture procedure includes:
- A. Monitoring Mrs. GC's color, pulse and respiration
- B. Labeling all laboratory specimens in numerical order
- C. Positioning Mrs. GC on her side with knees drawn up to her chest
- D. All of the above
Correct Answer: C
Rationale: During a lumbar puncture procedure, it is important to position the patient correctly to facilitate the procedure and minimize the risk of complications. Placing the patient on their side with their knees drawn up to their chest helps open up the spaces in the lower spine, making it easier for the healthcare provider to access the appropriate area for the procedure. This position also helps to minimize the risk of post-procedure complications such as spinal headaches. Monitoring the patient's vital signs is important but does not specifically relate to the nursing intervention during the lumbar puncture procedure. Labeling laboratory specimens in numerical order is also a routine task but not directly related to the procedure itself. Thus, the correct intervention during the lumbar puncture procedure is positioning the patient on their side with knees drawn up to the chest.
An oncology nurse educator is speaking to a women's group about breast cancer. Questions and comments from the audience reveal a misunderstanding of some aspects of the disease. Various members of the audience have made all of the following statements. Which one is accurate?
- A. Mammography is the most reliable method for detecting breast cancer.
- B. Breast cancer is the leading killer of women of childbearing age.
- C. Breast cancer requires a mastectomy.
- D. Men can develop breast cancer.
Correct Answer: D
Rationale: While all the statements made by the audience members may have been common misconceptions, the only one that is accurate is that men can develop breast cancer. Although it is less common in men than in women, breast cancer can still affect males. It is important for everyone to be aware of the risks and symptoms of breast cancer, regardless of gender.
Nurse Hannah is administering a steroid to a child diagnosed with idiopathic thrombocytopenic purpura (ITP); which of the following should the nurse monitor?
- A. Infection
- B. Anemia
- C. Bleeding
- D. Bruising
Correct Answer: C
Rationale: Idiopathic thrombocytopenic purpura (ITP) is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Steroids are often prescribed to help increase platelet production in patients with ITP. Therefore, the nurse should monitor the child for signs of bleeding, such as petechiae, ecchymosis, gum bleeding, and other unusual bleeding manifestations. Monitoring for bleeding is crucial to assess the effectiveness of the steroid treatment and to prevent complications associated with ITP.
A 4-year-old weighing 15 kg produces 150 mL of urine in 10 hours. What should the nurse do?
- A. Notify the physician; urine output is too low.
- B. Encourage increased oral intake.
- C. Record the urine output in the chart.
- D. Administer IV fluids to rehydrate.
Correct Answer: C
Rationale: Expected urine output is 0.5-1 mL/kg/hr. For a 15-kg child over 10 hours, 75-150 mL is within normal limits.