Nokea
A toddler who has been hospitalized for vomiting due to gastroenteritis is sleeping and difficult to wake up. Assessment reveals: HR: 220 beats per minute (regular) Respiratory rate: 30 per minute BP: 84/52 Capillary refill: 3 seconds Which dysrhythmia does the nurse suspect in this child?
- A. Rapid pulmonary flutter
- B. Sinus bradycardia
- C. Rapid atrial fibrillation
- D. Supraventricular tachycardia (SVT)
Correct Answer: D
Rationale: SVT is typically above 200 beats per minute and can result from dehydration; the rapid rate causes low cardiac output (CO), resulting in low BP and prolonged capillary refill.
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All the following are causes of heart failure in full-term neonate EXCEPT
- A. asphyxial
- B. coarctation of aorta
- C. hypoplastic left heart syndrome
- D. transposition of great arteries
Correct Answer: B
Rationale: Coarctation of the aorta may not immediately present with heart failure in full-term neonates.
Complement system:
- A. Is activated by bacterial endotoxins by the classical pathway
- B. Reduced C3 and C4 are usual findings in acute glomerulonephritis
- C. Hereditary angioneurotic oedema is caused by deficiency of one of the components of the classical pathway of the system
- D. Is part of humoral immunity
Correct Answer: D
Rationale: The complement system is a key component of humoral immunity, playing a role in the immune response to pathogens.
Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client?
- A. Avoid coiling the tubing and keep if free of kinks
- B. Cleanse the perineal area with soap and water twice daily
- C. Keep the drainage bag lower than the level of the bladder
- D. Drink 1,000 ml of fluids daily to irrigate catheter
Correct Answer: C
Rationale: Keeping the drainage bag lower than the bladder prevents backflow of urine, reducing the risk of infection.
Consequences of a median nerve section in the ante-cubital fossa include:
- A. Complete paralysis of pronation
- B. Loss of sensation over palmar aspect of middle finger
- C. Wasting of hypothenar eminence
- D. Paralysis of abductor pollicis brevis
Correct Answer: D
Rationale: The median nerve controls the abductor pollicis brevis, and its injury at the ante-cubital fossa results in an inability to perform thumb abduction.
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.