Nokea
An infant has been diagnosed with cow's milk allergy. What are the clinical manifestations the nurse expects to assess? (Select all that apply.)
- A. Pink mucous membranes
- B. Vomiting
- C. Rhinitis
- D. Abdominal pain
Correct Answer: B
Rationale: Pink mucous membranes are not a typical clinical manifestation of cow's milk allergy. Allergies often present with symptoms affecting the gastrointestinal tract, respiratory system, skin, or a combination of these systems.
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The nurse is caring for a school-age child who has had a cardiac catheterization. The child tells the nurse that the bandage is "too wet." The nurse finds the bandage and bed soaked with blood. What is the priority nursing action?
- A. Notify physician
- B. Apply new bandage with more pressure
- C. Place the child in Trendelenburg position
- D. Apply direct pressure above catheterization site
Correct Answer: D
Rationale: The priority nursing action in this situation is to apply direct pressure above the catheterization site to control the bleeding. This is important to prevent excessive blood loss and ensure the child's safety. The nurse should quickly address the issue of the soaked bandage and bed by applying direct pressure to the catheterization site to stop the bleeding. Once bleeding is controlled, the nurse should then notify the physician for further evaluation and treatment. Placing the child in Trendelenburg position is not necessary in this scenario, as the immediate focus should be on controlling the bleeding.
The nurse is caring for a client in the emergency room diagnosed with Bell's palsy. The client has been taking acetaminophen (Tylenol), and acetaminophen overdose is suspected. The nurse anticipates that the antidote to be prescribed is:
- A. Pentostatin (Nipent)
- B. Fludarabine (Fludara)
- C. Auranofin (Ridaura)
- D. Acetylcysteine Mucomyst)
Correct Answer: D
Rationale: Acetylcysteine (Mucomyst) is the antidote for acetaminophen (Tylenol) overdose. If an overdose of acetaminincophen is suspected, acetylcysteine should be administered within 8-10 hours of ingestion to prevent liver damage and failure. Pentostatin, Fludarabine, and Auranofin are not antidotes for acetaminophen overdose and are used for other medical conditions.
When administering spironolactone (Aldactone) to a client who has had a unilateral adrenalectomy, the nurse should instruct the client about which of the following possible adverse effects of the drug?
- A. Breast tenderness
- B. Increased facial hair
- C. Menstrual irregularities
- D. Hair loss
Correct Answer: C
Rationale: Spironolactone (Aldactone) is a potassium-sparing diuretic and aldosterone antagonist that is commonly used to treat conditions such as hypertension, heart failure, and edema. One of its common side effects is hormonal effects due to its antiandrogenic properties. In women, spironolactone can lead to menstrual irregularities, including amenorrhea (absence of menstrual periods) or breakthrough bleeding. Therefore, in a client who has had a unilateral adrenalectomy (removal of one adrenal gland), which can already disrupt hormonal balance, the nurse should educate the client about the potential for menstrual irregularities when taking spironolactone.
In assisting a physician to perform a thoracentesis to Mr. Sy, how should the nurse postion a patient with pleural effusion of the left lung?
- A. supine with the left arm extended over the head
- B. sitting at the side of the bed with both arms resting on alocked overbed table
- C. high fowler's with both arms resting on pillows
- D. semi-fowlers with both arms resting on pillows
Correct Answer: B
Rationale: In performing a thoracentesis for a patient with pleural effusion of the left lung, the patient should be positioned sitting at the side of the bed with both arms resting on an overbed table. This position allows for better access to the left lung area and helps the patient maintain a comfortable and stable position during the procedure. Sitting position also helps to expand the intercostal spaces, making it easier for the physician to access the pleural fluid. Additionally, having both arms resting on an overbed table helps the patient remain still and reduce the risk of injury during the procedure. Therefore, this position is the most suitable for performing a thoracentesis for a patient with pleural effusion of the left lung.
Which of the following is an early sign of anemia?
- A. Palpitations
- B. Pallor
- C. Glossitis
- D. Weight loss
Correct Answer: B
Rationale: Pallor, or paleness of the skin, is an early sign of anemia. Anemia occurs when there is a decrease in the number of red blood cells or the amount of hemoglobin in the blood, resulting in reduced oxygen supply to the body's tissues. This lack of oxygen can cause the skin to appear pale due to decreased blood flow. Other common symptoms of anemia may include fatigue, weakness, shortness of breath, dizziness, and cold hands and feet. Palpitations, glossitis, and weight loss are not typically early signs of anemia.