Nokea
For a client with low blood volume, what are the implications of decreasing blood pressure and a rapid heart rate?
- A. Compression of blood vessels due to blood loss
- B. Increase in the circulating blood volume
- C. Inadequate renal perfusion
- D. Hypovolemia and shock
Correct Answer: D
Rationale: In a client with low blood volume, a decrease in blood pressure and a rapid heart rate can indicate hypovolemia, which is a condition characterized by a decreased volume of circulating blood. This can lead to inadequate perfusion of vital organs, including the kidneys (choice C), as well as other tissues throughout the body. If left unaddressed, severe hypovolemia can progress to shock, a critical condition where there is inadequate blood flow to meet the body's metabolic demands. This can result in organ dysfunction and potentially life-threatening complications. Therefore, the implications of decreasing blood pressure and a rapid heart rate in a client with low blood volume are indicative of hypovolemia and the potential development of shock.
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Which of the ff is a reason for providing early discharge instructions and making arrangements for home care for clients undergoing mastectomy?
- A. The adverse effect of mastectomy are immediate
- B. The wound of the surgery is highly contagious and the client should exercise isolation precautions immediately after the procedure
- C. Most clients are not hospitalized long after a mastectomy
- D. The suicidal tendencies in the women undergoing a mastectomy are high
Correct Answer: C
Rationale: Most clients are not hospitalized long after a mastectomy. This is a key reason for providing early discharge instructions and making arrangements for home care for clients undergoing mastectomy. Typically, clients undergoing mastectomy have shorter hospital stays, often as part of the trend toward faster postoperative recovery and reduced healthcare costs. By ensuring that clients have appropriate home care arrangements and understand postoperative instructions early on, healthcare providers can support a smooth transition from the hospital to the home environment, promoting optimal recovery and outcomes for the client.
Building a tower by a 22-month-old child requires
- A. visual-motor coordination
- B. uses objects and actions in combination
- C. gross motor to solve problems
- D. fine motor and symbolic thought
Correct Answer: D
Rationale: At this age, building a tower involves fine motor skills and symbolic thinking.
Which refers to a newborn whose rate of intrauterine growth was slowed and whose birth weight falls below the 10th percentile on intrauterine growth charts?
- A. Postterm
- B. Postmature
- C. Low birth weight
- D. Small for gestational age
Correct Answer: D
Rationale: A newborn who is small for gestational age (SGA) refers to a baby whose rate of intrauterine growth was slowed, leading to a birth weight falling below the 10th percentile on intrauterine growth charts. SGA infants are at an increased risk for various health complications due to their smaller size at birth, such as difficulties in regulating body temperature, low blood sugar, and respiratory distress. Postterm refers to a pregnancy that has extended beyond 42 weeks, while postmature refers specifically to a fetus that has been in the womb beyond the expected due date. Low birth weight may refer to a baby born below a certain weight threshold regardless of gestational age.
The nurse is reviewing the patient's daily PT and INR levels. The PT level is 26 (normal = 9 to 12 seconds). Which of the ff. actions should the nurse take?
- A. Give the next dose of warfarin when it is ordered to be given.
- B. Inform physician before the next dose of warfarin is given. c.Stop the heparin infusion.
- C. Continue monitoring heparin infusion.
Correct Answer: B
Rationale: A PT level of 26 seconds is significantly above the normal range of 9 to 12 seconds. This indicates that the patient's blood is taking much longer to clot than usual, which may put the patient at risk for bleeding. It is important for the nurse to inform the physician before giving the next dose of warfarin because warfarin is a medication that helps prevent blood clots by thinning the blood. However, in this case, the patient's blood is already thin beyond the target range, so giving the next dose of warfarin without physician guidance may further increase the risk of bleeding. The physician may need to adjust the dose or recommend other interventions to manage the patient's PT levels effectively.
To combat the most common adverse effects of chemotherapy, the nurse would administer an:
- A. Antiemetic
- B. Antibiotic
- C. Antimetabolite
- D. Anticoagulant
Correct Answer: A
Rationale: The most common adverse effects of chemotherapy include nausea and vomiting, which can significantly impact the patient's quality of life. An antiemetic is a medication specifically designed to prevent or alleviate nausea and vomiting. By administering an antiemetic, the nurse can help manage these distressing side effects and improve the patient's overall comfort during chemotherapy treatments. Antibiotics are not typically used to combat the side effects of chemotherapy, and antimetabolites and anticoagulants do not address nausea and vomiting associated with chemotherapy.