Nokea
A patient admitted with gastrointestinal tract bleeding has a hemoglobin level of 6 g/dL. She asks the nurse why she feels SOB. Which response is best?
- A. "Anemia prevents your lungs from absorbing oxygen effectively."
- B. "You do not have enough hemoglobin to carry oxygen to your tissues."
- C. ""You don't have enough blood to feed your cells."
- D. "You have lost a lot of blood, and that has damaged your lungs."
Correct Answer: B
Rationale: The best response is option B, "You do not have enough hemoglobin to carry oxygen to your tissues." Hemoglobin is the protein in red blood cells that carries oxygen from the lungs to the tissues throughout the body. With a low hemoglobin level of 6 g/dL due to gastrointestinal tract bleeding, there is a reduced capacity to carry oxygen to the body's tissues. This decreased oxygen-carrying capacity leads to symptoms of shortness of breath (SOB) because the body's cells are not receiving an adequate supply of oxygen. It is important to provide a clear and accurate explanation to the patient about the relationship between hemoglobin, oxygen transport, and symptoms of anemia like shortness of breath.
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Which of the ff nursing interventions is involved when caring for a client with influenza?
- A. Maintaining airborne transmission
- B. Oxygen administration
- C. Immediate recognition of respiratory
- D. Complete bed rest distress
Correct Answer: C
Rationale: When caring for a client with influenza, immediate recognition of respiratory distress is crucial. Influenza can lead to respiratory complications such as pneumonia, which may result in respiratory distress. Early detection of symptoms such as increased respiratory rate, shortness of breath, and chest pain can help in providing prompt intervention and preventing further complications. Therefore, the nursing intervention involved in caring for a client with influenza is to closely monitor the respiratory status and quickly recognize any signs of respiratory distress. This proactive approach can potentially save the client's life and improve outcomes.
Rickets is caused by a deficiency in:
- A. vitamin A.
- B. vitamin C.
- C. vitamin D and calcium.
- D. folic acid and iron.
Correct Answer: C
Rationale: Rickets is a condition that primarily affects children and is characterized by softening and weakening of the bones, leading to skeletal deformities. This condition is caused by a deficiency in vitamin D and calcium. Vitamin D helps the body absorb calcium from the diet, and together they play a crucial role in bone health and development. Without enough vitamin D and calcium, the bones cannot mineralize properly, resulting in the characteristic symptoms of rickets. Other nutrients like vitamin A, vitamin C, folic acid, and iron do not directly cause rickets.
A child is brought to the emergency department experiencing an anaphylactic reaction to a bee sting. While an airway is being established, the nurse should prepare which medication for immediate administration?
- A. Diphenhydramine (Benadryl)
- B. Dobutamine (Dobutarex)
- C. Epinephrine (Adrenalin)
- D. Calcium chloride (calcium chloride)
Correct Answer: C
Rationale: In the management of anaphylaxis, the immediate medication of choice for administration is epinephrine. Epinephrine is a potent vasoconstrictor and bronchodilator which helps restore blood pressure and open up the airways during an anaphylactic reaction. It is the first-line treatment to reverse the potentially life-threatening effects of an allergic reaction. Other medications, like diphenhydramine or dobutamine, may be used as adjuncts later in the treatment, but epinephrine is crucial for immediate administration to stabilize the child's condition.
Mrs. Silang, a 52-year old female, is experiencing advanced hepatic cirrhosis now complicated by hepatic encephalopathy. She is confused, restless, and demonstrating asterixis. The nurse has formulated the nursing diagnosis: Altered thought processes related to which of the following?
- A. massive ascites formation
- B. fluid volume excess
- C. increased serum ammonia levels
- D. altered clotting mechanism
Correct Answer: C
Rationale: Hepatic encephalopathy is a neuropsychiatric complication of advanced liver disease, such as cirrhosis, where the liver's ability to metabolize ammonia is impaired. As a result, there is an increase in serum ammonia levels, leading to alterations in brain function and neurotransmission. Symptoms such as confusion, restlessness, and asterixis (flapping tremor) are characteristic of hepatic encephalopathy caused by increased ammonia levels affecting the brain. Therefore, altered thought processes in Mrs. Silang are primarily related to the increased serum ammonia levels rather than other factors like massive ascites formation, fluid volume excess, or altered clotting mechanism.
The nurse is caring for a patient, age 68, who is receiving digoxin (Lanoxin) 0.125 mg qd for cardiac myopathy. Which of the following assessments of the patient would indicate that he is experiencing a side effect of digoxin that requires follow-up?
- A. Skin flushing c.Hypertension
- B. Anorexia
- C. Constipation
Correct Answer: B
Rationale: Anorexia, or loss of appetite, is a common side effect of digoxin. It can lead to weight loss, weakness, and fatigue. Monitoring for anorexia is important because it may indicate digoxin toxicity, which can be serious and require intervention. Skin flushing is not a common side effect of digoxin. Hypertension is also not associated with digoxin use. Constipation is generally not a common side effect of digoxin. Therefore, anorexia is the assessment that indicates a potential side effect of digoxin that requires follow-up.