Nokea
During which stage of injury repair does the wound show evidence of erythema and edema, and phagocytosis begins?
- A. Proliferation
- B. Inflammation
- C. Hemostasis
- D. Maturation
Correct Answer: B
Rationale: The inflammation stage (B) involves erythema, edema, and phagocytosis as the body responds to injury. Other stages (A, C, D) have different processes.
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A client in cardiac arrest shows to be in torsades de pointes, and magnesium sulfate is ordered STAT. The priority nursing intervention is
- A. monitor client for bradycardia and respiratory depression.
- B. prepare client for synchronized cardioversion.
- C. monitor client for tachycardia and hyperventilation.
- D. prepare client for Swan catheter.
Correct Answer: A
Rationale: Magnesium sulfate for torsades de pointes can cause bradycardia and respiratory depression, requiring close monitoring.
Which statement is true regarding the infant's susceptibility to pertussis?
- A. If the mother had pertussis, the infant will have passive immunity.
- B. Most infants and children are highly susceptible from birth.
- C. The newborn will be immune to pertussis for the first few months of life.
- D. Infants under 1 year of age seldom get pertussis.
Correct Answer: B
Rationale: Infants are highly susceptible to pertussis from birth, as maternal immunity is minimal, and severe cases are common in this age group.
The nurse is completing the preoperative checklist on a client scheduled for surgery and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?
- A. Call the surgeon and ask him to come see the client to clarify the information
- B. Explain the procedure and complications to the client
- C. Check in the physician's progress notes to see if understanding has been documented
- D. Check with the client's family to see if they understand the procedure fully
Correct Answer: A
Rationale: Informed consent requires that the client understands the procedure and its risks. If the client is unclear, the surgeon, as the primary provider, should clarify the information to ensure the client's understanding, as this is a legal and ethical requirement.
The nurse is making a home visit to an elderly client during the summer. Upon arrival, the nurse notices the refrigerator and freezer doors are open as the client is using both for air conditioning. Which of the following actions by the nurse are most appropriate?
- A. instruct the client to place a fan in front of the freezer to enhance circulation of cool air
- B. hold a meeting with the client and family to advise them of the safety risks of this practice
- C. note this observation in the client's medical record, but do not discuss with the client
- D. report the incident to the nursing supervisor
Correct Answer: B
Rationale: Discussing the risks (e.g., food spoilage, electrical hazards) with the client and family promotes safety and education.
Following a heart transplant, a client is started on medication to prevent organ rejection. Which category of medication prevents the formation of antibodies against the new organ?
- A. Antivirals
- B. Antibiotics
- C. Immunosuppressants
- D. Analgesics
Correct Answer: C
Rationale: Immunosuppressants, such as cyclosporine, prevent the immune system from forming antibodies against the transplanted heart.