Nokea
Fluids are restricted to 1,500 ml daily for a male client with acute kidney injury (AKI). He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. Which intervention should the nurse implement?
- A. Remove all sources of liquids from the client's room
- B. Allow family to give client a measured amount of ice chips
- C. Restrict family visiting until the client's condition is stable
- D. Provide the client with oral swabs to moisten his mouth
Correct Answer: D
Rationale: Oral swabs can help alleviate thirst without increasing fluid intake, which is restricted in AKI.
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All of the following are conditions with combined cellular and antibody immunodeficiency, except
- A. Ataxia telangiectasia
- B. Reticular dysgenesis
- C. Common variable immunodeficiency
- D. Severe combined immunodeficiency
Correct Answer: C
Rationale: Common variable immunodeficiency (CVID) is primarily an antibody deficiency, not a combined immunodeficiency.
A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?
- A. Strong foul-smelling flatus
- B. Gastroccult positive emesis
- C. Complaint of poor night vision
- D. Loose bowel movements
Correct Answer: B
Rationale: Gastroccult positive emesis indicates gastrointestinal bleeding, which requires immediate intervention to prevent further complications.
A 2-month-old male presents with tachycardia, dyspnea, tachypnea, and a gallop rhythm with no heart murmur. He was perfectly well until 1 day prior to the episode. The physical examination reveals a heart rate of 235, a temperature of 37.8°C, and a normal blood pressure with warm, well-perfused extremities. The most likely diagnosis is
- A. sepsis
- B. supraventricular tachycardia
- C. ingestion
- D. ventricular tachycardia
Correct Answer: B
Rationale: Supraventricular tachycardia can cause rapid heart rates and heart failure in infants.
Clubbing is found in:
- A. Crohn's disease
- B. Bronchiectasis
- C. Rheumatic fever
- D. Infective endocarditis
Correct Answer: B
Rationale: Clubbing is commonly associated with chronic respiratory conditions such as bronchiectasis, due to chronic hypoxia and inflammation.
Surgical repair of VSD should be considered at the time of diagnosis
- A. small supracristal VSD
- B. VSD with heart failure
- C. hemodynamically restrictive VSD
- D. significant VSD
Correct Answer: B
Rationale: Significant or symptomatic VSDs warrant early surgical intervention.