Nokea
A patient is being given penicillin via IV piggyback and develops an anaphylactic reaction. Which of the following should be the nurse's first action?
- A. Call the doctor
- B. Maintain the antibiotic
- C. Call for help
- D. Turn off the antibiotic
Correct Answer: D
Rationale: In the scenario of a patient developing an anaphylactic reaction to penicillin via IV piggyback, the nurse's first action should be to discontinue the administration of the antibiotic to prevent further exposure and potential worsening of the reaction. Turning off the antibiotic is critical as it stops the source of the allergic reaction. This step takes precedence over any other actions including calling the doctor, maintaining the antibiotic, or calling for help, as stopping the infusion is the most immediate and important action to take in managing an anaphylactic reaction. Once the antibiotic has been turned off, the nurse can then proceed with providing appropriate emergency treatments and notifying the healthcare team for further management.
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A neonate, who was delivered by Cesarean section for a breech presentation, is being examined in the neonatal nursery. For which of the following complications should the nurse carefully assess the baby?
- A. Developmental dysplasia of the hips (DDH)
- B. Legg-Calve-Perthes (LCP)
- C. Duchenne muscular dystrophy (DMD)
- D. Slipped capital femoral epiphysis (SCFE)
Correct Answer: A
Rationale: A neonate delivered by Cesarean section for a breech presentation is at higher risk for developmental dysplasia of the hips (DDH). Breech presentation, especially frank breech, increases the chance of hip instability and DDH due to the positioning of the legs in utero. DDH is a condition where the ball and socket joint of the hip does not properly form, leading to potential dislocation of the hip joint. It is important for the nurse to carefully assess the neonate for signs of hip dysplasia, such as limited hip abduction or asymmetry in the thigh folds, to facilitate early detection and intervention for optimal outcomes. Legg-Calve-Perthes (LCP), Duchenne muscular dystrophy (DMD), and slipped capital femoral epiphysis (SCFE) are not specifically related to breech delivery, and therefore, are less likely to be
Why must clients who will undergo diagnostic skin test avoid taking antihistamine or cold preparations for at least 48-72 hrs before testing?
- A. Antihistamines may increase the potential for excessive bleeding
- B. Antihistamines may aggravate the allergic reaction
- C. Antihistamines may increase the potential for false negative results
- D. Antihistamines may cause wheezing
Correct Answer: C
Rationale: Antihistamines are medications commonly used to relieve symptoms of allergies, including itching, sneezing, and hives. When a client undergoing a diagnostic skin test for allergies takes antihistamines, it can suppress the body's allergic response, leading to false negative results. This means that the test may not accurately identify all the substances to which the client is allergic, potentially leading to a misdiagnosis. To ensure the accuracy of the skin test, clients are advised to avoid taking antihistamines or cold preparations for at least 48-72 hours before the testing to allow their body to exhibit the appropriate allergic response.
The parents of a 3-month-old infant report that their infant sleeps supine (face up) but is often prone (face down) while awake. What knowledge should the nurse's response should be based?
- A. Unacceptable because of the risk of sudden infant death syndrome (SIDS)
- B. Unacceptable because it does not encourage achievement of developmental milestones
- C. Acceptable to encourage fine motor development
- D. Acceptable to encourage head control and turning over
Correct Answer: D
Rationale: The correct knowledge that the nurse's response should be based on is that it is acceptable to encourage head control and turning over. At 3 months of age, encouraging the infant to be prone while awake can help promote the development of head control, neck strength, and eventually facilitate the ability to turn over. This practice is considered safe and beneficial for infants within the appropriate age range, as long as the infant is supervised during the awake period. It is important to promote safe sleep practices for infants to reduce the risk of Sudden Infant Death Syndrome (SIDS), but allowing supervised tummy time for an awake infant is beneficial for their motor development.
Mrs. Baker was instructed by the nurse on foods to encourage her child's diet concerning the latter's iron deficiency anemia; which of the following if stated by the mother would indicate the need for further instruction?
- A. Fish
- B. Lean meats
- C. Whole-grain breads
- D. Yellow vegetables
Correct Answer: D
Rationale: Yellow vegetables do not contain a significant amount of iron compared to the other options provided (fish, lean meats, and whole-grain breads). Therefore, if Mrs. Baker indicates that she plans to focus on yellow vegetables to address her child's iron deficiency anemia, further instruction would be necessary to help her choose more iron-rich sources of food to improve her child's condition.
Which describes marasmus?
- A. Deficiency of protein with an adequate supply of calories
- B. Not confined to geographic areas where food supplies are inadequate
- C. Syndrome that results solely from vitamin deficiencies
- D. Characterized by thin, wasted extremities and a prominent abdomen resulting from edema (ascites)
Correct Answer: D
Rationale: Marasmus is a form of severe malnutrition characterized by a deficiency of both calories and protein in the diet. It typically occurs in young children and is often associated with a lack of adequate food intake. The classic presentation of marasmus includes extreme wasting of muscle and fat tissues, resulting in a gaunt appearance with thin limbs and a distended abdomen due to diminished muscle and subcutaneous fat. This differentiates it from kwashiorkor, another form of severe acute malnutrition characterized by edema and a protruding belly but with retained muscle mass. Therefore, option D, characterized by thin, wasted extremities and a prominent abdomen resulting from edema (ascites), accurately describes marasmus.