Nokea
During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within the first hour. What action should the nurse implement?
- A. Palpate for abdominal distention
- B. Send fluid to the lab for analysis
- C. Continue to monitor the fluid output
- D. Clamp the drainage tube for 5 minutes
Correct Answer: C
Rationale: Monitoring fluid output is essential to assess for complications such as reaccumulation of fluid or bleeding.
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Chief organ systems affected in acute graft-versus-host reaction are:
- A. Skin
- B. Renal system
- C. Gut
- D. CNS
Correct Answer: A
Rationale: The skin is one of the primary organ systems affected in acute graft-versus-host disease. The renal system, gut, and CNS can also be affected, but the skin is the most commonly involved.
Hemolytic anaemia is characterised by:
- A. Increased haptoglobin
- B. Haemosiderinuria
- C. Polychromasia
- D. Megaloblastic bone marrow
Correct Answer: B
Rationale: Haemosiderinuria: Hemolytic anaemia often leads to the release of heme, which is broken down into hemosiderin, leading to haemosiderinuria (presence of hemosiderin in urine).
The nurse is preparing a client for discharge who was recently diagnosed with Addison's disease. Which instruction is most important for the nurse to include in the client's discharge teaching plan?
- A. Use a walker when weakness occurs
- B. Avoid extreme environmental temperatures
- C. Increase daily intake of sodium in diet
- D. Take prescribed cortisone accurately
Correct Answer: D
Rationale: Taking prescribed cortisone accurately is crucial for managing Addison's disease and preventing an adrenal crisis.
The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever. The nurse knows that which laboratory study would assist in confirming the diagnosis?
- A. Immunoglobulin
- B. Red blood cell count
- C. White blood cell count
- D. Anti-streptolysin O titer
Correct Answer: D
Rationale: The Anti-streptolysin O titer is used to confirm a diagnosis of rheumatic fever as it indicates a recent streptococcal infection, which is a precursor to rheumatic fever.
In utero heart failure, often with fetal pleural and pericardial effusions and generalized ascites (nonimmune hydrops fetalis) may occur in
- A. ventricular septal defect
- B. coarctation of aorta
- C. d-Transposition of great arteries
- D. single ventricle
Correct Answer: D
Rationale: Single ventricle anatomy can lead to in utero heart failure and hydrops fetalis.