Nokea
For which of the following adverse effects should the nurse monitor?
- A. Prolonged wound healing
- B. Nausea
- C. Stevens-Johnson syndrome
- D. Renal failure
Correct Answer: B
Rationale: The correct answer is B: Nausea. The nurse should monitor for nausea as it is a common adverse effect of many medications and can impact the patient's overall well-being. Nausea can lead to decreased appetite, dehydration, and noncompliance with medications. Prolonged wound healing (A) is a potential adverse effect but is not as common or immediate as nausea. Stevens-Johnson syndrome (C) is a severe and life-threatening skin reaction that is rare and not typically monitored by nurses. Renal failure (D) is a serious adverse effect but may not be directly related to all medications.
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Which of the following statements by the guardian indicates an understanding of the teaching?
- A. I will ensure that my child consumes a high-calorie diet.
- B. I will expect my child to need annual sweat chloride testing.
- C. I will have my child chew the pancrelipase medication before eating.
- D. I will administer dormase alfa every 4 hours for wheezing.
Correct Answer: A
Rationale: The correct answer is A because ensuring the child consumes a high-calorie diet demonstrates an understanding of the teaching regarding managing cystic fibrosis, a condition that requires a high-calorie intake to maintain weight and overall health. This statement aligns with the need for nutritional support in cystic fibrosis management.
Choice B is incorrect because annual sweat chloride testing is not related to dietary management. Choice C is incorrect as chewing pancrelipase medication before eating is not necessary for understanding the teaching about cystic fibrosis. Choice D is incorrect as administering dormase alfa every 4 hours for wheezing does not pertain to dietary requirements in cystic fibrosis.
Which of the following laboratory findings should the nurse expect?
- A. Decreased prothrombin time
- B. Increased Hgb level
- C. Increased RBC
- D. Decreased platelet count
Correct Answer: D
Rationale: The correct answer is D: Decreased platelet count. This is expected in a patient with thrombocytopenia, which is a condition characterized by low platelet levels. Thrombocytopenia can lead to abnormal bleeding and bruising due to impaired blood clotting.
A: Decreased prothrombin time would not be expected in thrombocytopenia, as it measures the clotting ability of the plasma, not platelets.
B: Increased Hgb level and C: Increased RBC levels are not typically associated with thrombocytopenia.
In summary, a decreased platelet count is the most relevant laboratory finding to expect in a patient with thrombocytopenia.
Which of the following findings should the nurse report to the provider?
- A. Drainage from the chest tube of 22 mL in the last hour
- B. Urine output of 15 mL in the last 2 hr
- C. Skin temperature 36° C (96.8° F)
- D. Pedal and posterior tibial pulses of 2+
Correct Answer: B
Rationale: The correct answer is B: Urine output of 15 mL in the last 2 hr. Inadequate urine output can indicate renal impairment or inadequate fluid intake. This is a critical finding that needs immediate attention to prevent further complications like acute kidney injury. A: Drainage from the chest tube of 22 mL in the last hour is within the normal range. C: Skin temperature of 36°C (96.8°F) is within normal limits. D: Pedal and posterior tibial pulses of 2+ indicate normal circulation.
Which of the following findings should the nurse identify as a manifestation of scabies?
- A. Scaly lesions on the inner thighs
- B. Rash with red macular lesions on the scalp
- C. Bull's eye edematous area on the groin
- D. Maculopapular skin burrows on the hand
Correct Answer: D
Rationale: The correct answer is D: Maculopapular skin burrows on the hand. Scabies is caused by the Sarcoptes scabiei mite, which burrows into the skin, causing characteristic burrows that appear as thin, wavy, and slightly raised grayish-white or skin-colored lines. These burrows are commonly found on the hands, fingers, wrists, and interdigital spaces. Scaly lesions on the inner thighs (A) are more indicative of fungal infections. Rash with red macular lesions on the scalp (B) is more suggestive of conditions like seborrheic dermatitis or psoriasis. A bull's eye edematous area on the groin (C) is more characteristic of Lyme disease. In summary, the presence of maculopapular skin burrows on the hand is a key manifestation of scabies, differentiating it from the other options provided.
Which of the following findings indicates proper functioning of the child's trigeminal nerve?
- A. The child maintains balance when standing with eyes closed.
- B. The child exhibits a gag reflex when stimulated with a tongue blade.
- C. The child correctly identifies specific scents.
- D. The child has symmetrical jaw strength when biting down.
Correct Answer: D
Rationale: The correct answer is D because symmetrical jaw strength when biting down indicates proper functioning of the trigeminal nerve, which controls the muscles of mastication. Choice A relates to the vestibular system, not the trigeminal nerve. Choice B involves the glossopharyngeal and vagus nerves. Choice C is related to the olfactory nerve.