Nokea
At what age can most infants sit steadily unsupported?
- A. 4 months
- B. 6 months
- C. 8 months
- D. 10 months
Correct Answer: C
Rationale: Most infants can sit steadily unsupported at around 8 months of age. By this time, they have developed sufficient strength and control in their core muscles to sit up without support. It is important for parents to provide a safe environment for their infants to practice sitting up and to always supervise them during this milestone development.
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Which of the following IV solutions is hypertonic?
- A. Normal saline
- B. 0.45% NaCl
- C. 5% dextrose in 0.9% NaCl
- D. 0.225% NaCl
Correct Answer: C
Rationale: A hypertonic solution has a higher concentration of solutes compared to the intracellular fluid. In this case, 5% dextrose in 0.9% NaCl is hypertonic because it has a higher osmolarity due to the combined effect of dextrose and sodium chloride. The dextrose contributes to the hypertonicity, making the overall solution more concentrated than the intracellular fluid.
The nurse administered neutral protamine Hagedorn (NPH) insulin to a diabetic client at 7am. At what time would the nurse expect the client to be at most risk for a hypoglycemic reaction?
- A. 10:00 AM
- B. 4:00 PM
- C. Noon
- D. 10:00 PM
Correct Answer: D
Rationale: NPH insulin typically peaks in its action around 6-10 hours after administration. Therefore, after administering NPH insulin at 7am, the client would be at most risk for a hypoglycemic reaction around 10pm. This is when the insulin is exerting its strongest effect, potentially leading to lower blood sugar levels. Monitoring for hypoglycemia during this time frame is crucial to ensure prompt intervention if needed.
After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should highest priority to which intervention?
- A. Serving small portions bland food
- B. Encouraging rhythmic breathing exercises
- C. Administering metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed
- D. Withholding fluids for the first 4 to 6 hours after chemotherapy administration
Correct Answer: C
Rationale: Administering metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed should be the highest priority intervention for a client experiencing nausea and vomiting after cancer chemotherapy. Metoclopramide is a commonly used antiemetic medication that helps to reduce nausea and vomiting by enhancing gastric emptying and decreasing nausea. Dexamethasone, a corticosteroid, can also help alleviate inflammation that may contribute to the nausea and vomiting. By administering these medications as prescribed, the nurse can effectively address the client's symptoms and improve their comfort level. The other options, such as serving small portions bland food, encouraging rhythmic breathing exercises, and withholding fluids, are important interventions but should not take precedence over providing the prescribed antiemetic medications to manage the client's post-chemotherapy symptoms.
When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea and itching. When urticarial, tachycardia, and hypotension develop, the nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction?
- A. Type I (immediate, anaphylactic) hypersensitivity reaction
- B. Type II (cytolytic, cytotoxic) hypersensitivity reaction
- C. Type III (immune complex) hypersensitivity reaction
- D. Type IV (cell-mediated, delayed) hypersensitivity reaction
Correct Answer: A
Rationale: The symptoms described in the scenario, such as chest pain, nausea, itching, urticaria, tachycardia, and hypotension, are indicative of an immediate hypersensitivity reaction, also known as a Type I hypersensitivity reaction. This type of reaction is triggered by the release of histamine and other inflammatory mediators from mast cells and basophils. Symptoms can range from mild to severe and can manifest rapidly after exposure to the allergen, in this case, the blood transfusion. Common manifestations include skin reactions (e.g., itching, urticaria), respiratory symptoms (e.g., chest pain, wheezing), cardiovascular changes (e.g., tachycardia, hypotension), and gastrointestinal symptoms (e.g., nausea, vomiting).
An elderly client develops severe bone marrow depression from chemotheraphy for cancer of the prostate. The nurse should;
- A. Monitor Intake and output of fluids
- B. Increase dally intake of fluids
- C. Use a soft toothbrush for oral hygiene HEMATOPOIETIC AND LYMPHATIC SYSTEMS
Correct Answer: A
Rationale: Monitoring intake and output of fluids is essential for an elderly client who develops severe bone marrow depression from chemotherapy for prostate cancer. Bone marrow depression can result in decreased production of blood cells, including red blood cells, white blood cells, and platelets. Monitoring intake and output of fluids helps assess hydration status and kidney function. Decreased fluid intake or output may indicate kidney damage or dehydration, which are common concerns in clients with bone marrow depression. Therefore, it is crucial for the nurse to monitor the client's fluid balance closely to ensure optimal functioning of the kidneys and prevent complications related to bone marrow suppression.