Nokea
Aling Nena, 68 years old, had a MVA and underwent surgery for hip fracture. Two days post-surgery, she suddenly complained of chest heaviness despite the absence of cardiac history. What is the nursing priority?
- A. document the onset, duration, severity, and precipitating factors
- B. may offer analgesics for chest pain
- C. administer oxygen via face mask
- D. inform the physician about the heaviness
Correct Answer: C
Rationale: In a post-operative patient, sudden chest heaviness can be a sign of various complications, such as a pulmonary embolism or cardiac issue. One of the immediate nursing interventions for a patient complaining of chest heaviness is to ensure adequate oxygenation. Administering oxygen via a face mask can help improve oxygenation and provide relief while further assessments are being done to determine the cause of the symptom. This intervention takes priority over documenting the symptom, offering analgesics, or informing the physician, as addressing the patient's oxygen needs is crucial in this situation.
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A college student goes to the college clinic and asks the best way to avoid contracting an STD. The nurse provides the clinic's standard STD teaching. Which statement by the student indicates the need for additional instruction?
- A. "There is no guarantee that I won't contract an STD if I choose to be sexually active."
- B. "Abstinence is the only sure way to avoid an STD."
- C. "If I use a condom with spermicide, I will be safer than if I don't use one."
- D. "If I question my partner about past sexual encounters, I can avoid STDs."
Correct Answer: D
Rationale: The statement "If I question my partner about past sexual encounters, I can avoid STDs" indicates a need for additional instruction. While communication with a partner about sexual history is important, relying solely on questioning a partner is not a foolproof method of avoiding STDs. Some individuals may not disclose their complete sexual history or may be unaware that they have an STD. It is crucial to emphasize the importance of using protection such as condoms consistently and correctly, getting tested regularly, and practicing safe sex in general.
A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome?
- A. Hypotension and Bradycardia
- B. Tachypnea and retractions
- C. Acrocyanosis and grunting
- D. The presence of a barrel chest with grunting
Correct Answer: B
Rationale: Respiratory distress syndrome (RDS), also known as hyaline membrane disease, is a condition commonly seen in preterm newborn infants. The two classic signs of RDS are tachypnea (rapid breathing) and retractions. Tachypnea is defined as a respiratory rate greater than 60 breaths per minute in newborn infants. Retractions refer to visible indrawing of the chest wall with each breath, indicating increased work of breathing. These signs are indicative of the infant's struggle to breathe and can suggest the presence of RDS. While acrocyanosis (bluish discoloration of the extremities) and grunting may also be present in infants with RDS, tachypnea and retractions are more specific indicators of respiratory distress. Hypotension and bradycardia are not common signs of RDS. The presence of a barrel chest with grunting is not specific
Idiopathic thrombocytopenic purpura (ITP) commonly results in what finding?
- A. Blood clots
- B. Pallor
- C. Dry membranes
- D. Bruising
Correct Answer: D
Rationale: Idiopathic thrombocytopenic purpura (ITP) is a condition characterized by a low platelet count, leading to an increased risk of bleeding and easy bruising. Platelets are responsible for blood clotting and when their count is low, it can result in purpura (bruising) due to small blood vessels leaking blood into the skin. For this reason, the most common finding in ITP is bruising rather than blood clots, pallor, or dry membranes.
Which vitamin is recommended for all women of childbearing age to reduce the risk of neural tube defects such as spina bifida?
- A. A
- B. C
- C. Niacin
- D. Folic acid
Correct Answer: D
Rationale: Folic acid is the correct answer. All women of childbearing age are recommended to take folic acid to reduce the risk of neural tube defects such as spina bifida in their offspring. Neural tube defects occur in the early stages of pregnancy, often before a woman even knows she is pregnant, which is why it is important for all women of childbearing age to ensure they have adequate folic acid intake. Folic acid is a B vitamin that helps the body make new cells and plays a crucial role in the development of the baby's neural tube, which eventually becomes the brain and spinal cord. Adequate folic acid intake before and during pregnancy can significantly reduce the risk of neural tube defects. That's why it is recommended for all women of childbearing age to take a daily folic acid supplement or consume foods fortified with folic acid.
A first-time mother brings in her 5-day-old baby for a well-child visit. The baby weighs 7 lb 5 oz, down from 7 lb 10 oz at discharge. The nurse's best response is:
- A. I will notify the doctor about this weight loss.
- B. Newborns can lose up to 10% of their birth weight and regain it by 2 weeks of age.
- C. I can tell you are a first-time mother; don't worry.
- D. Maybe the baby isn't getting enough milk. How often are you feeding?
Correct Answer: B
Rationale: A small weight loss is normal in the first week of life; infants typically regain their birth weight by 2 weeks.