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For a client with sickle cell anemia, how does the nurse assess for jaundice?
- A. The nurse assesses mental status, verbal ability, and motor strength
- B. The nurse observes the joints for signs of swelling
- C. The nurse inspects the skin and sclera for jaundice
- D. The nurse collects a urine specimen
Correct Answer: C
Rationale: In a client with sickle cell anemia, jaundice is a common manifestation due to the breakdown of red blood cells. The nurse should inspect the skin and sclera for signs of jaundice, which presents as a yellow discoloration. This assessment helps in identifying the presence and severity of jaundice in the client, which can be indicative of ongoing hemolysis and the need for further interventions. Monitoring for jaundice is important in managing clients with sickle cell anemia to address complications early and provide appropriate care.
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A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother?
- A. Switch to bottle feeding the baby for 2 weeks
- B. Stop the breast feedings and switch to bottle-feeding permanently
- C. Feed the newborn infant less frequently
- D. Continue to breastfeed every 2-4 hours.
Correct Answer: D
Rationale: The most appropriate instruction for a mother of a newborn infant with hyperbilirubinemia who is being breastfed is to continue to breastfeed every 2-4 hours. Breastfeeding should be initiated within 2 hours after birth and continued every 2-4 hours thereafter. Breast milk helps to promote the passage of meconium (the dark green stools of the newborn) and reduce the risk of hyperbilirubinemia. It is important to continue breastfeeding to establish and maintain a good milk supply, promote bonding between mother and baby, and provide important nutrients to the newborn. Switching to bottle feeding or feeding the newborn infant less frequently is not recommended in this case.
Which of the ff conditions is evident by persistent hoarseness?
- A. Bacterial infection
- B. Aphonia
- C. Laryngeal cancer
- D. Peritonsillar abscess
Correct Answer: C
Rationale: Persistent hoarseness is often a symptom of laryngeal cancer. Laryngeal cancer affects the voice box, leading to changes in voice quality, such as hoarseness. It is important to seek medical evaluation if hoarseness lasts for more than two weeks, as early detection and treatment of laryngeal cancer can improve outcomes. Bacterial infection, aphonia (loss of voice), and peritonsillar abscess are not typically associated with persistent hoarseness as a primary symptom.
Mrs. Go is suspected of experiencing respiratory distress from a left-sided pneumothorax. She should be positioned:
- A. in a semi-fowler's position
- B. trendelenburg position
- C. prone position
- D. on the right side
Correct Answer: A
Rationale: Mrs. Go, who is suspected of experiencing respiratory distress from a left-sided pneumothorax, should be positioned in a semi-fowler's position. This position involves elevating the head of the bed to approximately 30 to 45 degrees. Placing the patient in a semi-fowler's position helps improve lung expansion, facilitates breathing, and promotes optimal oxygenation. It can also help prevent the collapse of the affected lung and assist in reducing the symptoms associated with pneumothorax. Trendelenburg position (B) and prone position (C) are not recommended for pneumothorax as they can worsen the condition by putting additional pressure on the affected lung. Placing the patient on the right side (D) would not specifically address the respiratory distress caused by a left-sided pneumothorax. Therefore, the most appropriate position for Mrs. Go in this situation is the semi-fowler's position.
Which of the following intravenous solutions is hypotonic?
- A. Normal saline
- B. Ringer's lactate
- C. 0.45% saline
- D. 5% dextrose in normal saline  A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET F
Correct Answer: C
Rationale: A hypotonic solution has a lower concentration of solutes compared to the cells in the body. 0.45% saline is hypotonic because it has a lower concentration of sodium chloride compared to the normal extracellular fluid in the body. When this solution is administered intravenously, water will move into the cells to balance the concentration gradient, potentially causing cellular swelling. A hypotonic solution is used to rehydrate cells in cases of hypernatremia or dehydration with cellular dehydration.
Which side effects should the nurse monitor when a child is taking an antipsychotic medication? (Select all that apply.)
- A. Extrapyramidal effects
- B. Hypertension
- C. Bradycardia
- D. Dizziness
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.