Nokea
An adult has a central venous line. Which of the following should the nurse include in the plan of care?
- A. Complete blood count and electrolytes
- B. Regular chest x rays to ensure proper placement of the central line
- C. Continuous infusion of the solution at a keep vein open rate
- D. Any signs of infection, air embolus, and leakage or puncture
Correct Answer: D
Rationale: An adult with a central venous line should include monitoring for any signs of infection, air embolus, and leakage or puncture in the plan of care. Central venous lines carry a risk of complications such as infection, air embolism, and mechanical issues like leakage or puncture. These complications can be serious and require immediate attention to prevent further harm to the patient. Regular monitoring and assessment for these potential issues are crucial in providing safe care for a patient with a central venous line. Other options (A, B, C) may be important in the overall care but monitoring for complications is the priority.
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The nurse is conducting a staff in-service on appearance of childhood skin conditions. Lymphangitis ("streaking") is frequently seen in which condition?
- A. Cellulitis
- B. Folliculitis
- C. Impetigo contagiosa
- D. Staphylococcal scalded skin
Correct Answer: A
Rationale: Lymphangitis, characterized by "streaking" of red lines extending from the site of infection, is frequently seen in cellulitis. Cellulitis is a bacterial skin infection that affects the deeper layers of the skin and subcutaneous tissues. The red streaking in lymphangitis indicates an infection and inflammation of the lymphatic vessels, which are responsible for removing waste and fluids from the tissues. In cellulitis, bacteria enter the skin through a crack or break, leading to infection, inflammation, and the characteristic presentation of lymphangitis. This condition requires prompt medical attention and treatment with antibiotics to prevent further complications.
Which statement by the mother of an 18-month-old would lead the nurse to believe that the child should be referred for further evaluation for developmental delay?
- A. My child is able to stand but is not yet taking steps independently.
- B. My child has a vocabulary of approximately 15 words.
- C. My child is still sucking his thumb.
- D. My child seems to be quite wary of strangers.
Correct Answer: A
Rationale: By 15 to 18 months, most toddlers should be walking independently. An 18-month-old who is not yet walking warrants further evaluation.
Kasabach-Merritt syndrome is characterized by all the following EXCEPT
- A. thrombocytopenia
- B. microangiopathic hemolytic anemia
- C. coagulopathy
- D. association with infantile hemangiomas
Correct Answer: D
Rationale: Kasabach-Merritt syndrome is not typically associated with hemangiomas.
A client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis?
- A. Stool hematest
- B. Abdominal computed tomography (CT)
- C. Carcinoembryonic antigen (CEA) scan
- D. Sigmoidoscopy
Correct Answer: D
Rationale: Sigmoidoscopy is a diagnostic study that allows direct visualization of the lower part of the colon and rectum using a flexible tube with a camera at its end, called a sigmoidoscope. This procedure enables the healthcare provider to visually inspect the lining of the colon and rectum, identify any abnormal growths, such as tumors or polyps, and obtain tissue samples for biopsy if necessary. In the case of suspected colorectal cancer, sigmoidoscopy is crucial for confirming the diagnosis by directly visualizing any cancerous lesions or abnormal tissue changes in the colon and rectum. Other diagnostic tests, such as stool hematest, abdominal CT, and CEA scan, may aid in the evaluation and staging of colorectal cancer but are not as effective in confirming the diagnosis as sigmoidoscopy. Thus, sigmoidoscopy is the preferred diagnostic study for definitively diagnosing colorectal cancer in a client suspected of having the disease.
Which nursing action is most appropriate for the weak patient with osteoporosis?
- A. Maintain bedrest
- B. Ambulate with assistance
- C. Encourage fluids
- D. Provide a high-protein diet
Correct Answer: B
Rationale: For a weak patient with osteoporosis, it is important to promote mobility and weight-bearing activities to help maintain bone strength and prevent further bone loss. Ambulating with assistance can help improve muscle strength and balance, reducing the risk of falls and fractures. Maintaining bedrest can lead to further weakness and bone loss, so it is not the most appropriate action in this case. Encouraging fluids and providing a high-protein diet are important for overall health and healing but might not directly address the specific needs of a weak patient with osteoporosis.