Nokea
How does the nurse assess a child's capillary refill time?
- A. Inspecting the chest
- B. Auscultating the heart
- C. Palpating the apical pulse
- D. Palpating the skin to produce a slight blanching
Correct Answer: D
Rationale: Capillary refill time is a clinical assessment used to evaluate peripheral perfusion. To perform this assessment on a child, the nurse would gently press on the child's nail bed or skin, causing the area to momentarily blanch (turn white) as blood is temporarily forced out of the capillaries. Once pressure is released, the nurse observes and times how quickly the color returns to normal. A normal capillary refill time in a child is less than 2 seconds. This method helps the nurse determine if the child's peripheral circulation is adequate. Inspecting the chest (choice A), auscultating the heart (choice B), and palpating the apical pulse (choice C) are not appropriate methods for assessing capillary refill time.
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Which of the ff is the most severe complication among clients with allergies, regardless of type?
- A. Bronchitis
- B. Anaphylactic shock and angioneurotic
- C. Cardiac arrest edema
- D. Asthma and nasal polyps
Correct Answer: B
Rationale: Among clients with allergies, regardless of type, anaphylactic shock and angioneurotic edema are the most severe complications. Anaphylactic shock is a severe, potentially life-threatening allergic reaction that can occur rapidly and affect multiple organ systems, leading to a sudden drop in blood pressure and difficulty breathing. Angioneurotic edema, also known as angioedema, is another serious allergic reaction that involves swelling of the deep layers of the skin, often around the eyes and lips, but can also affect the throat and other areas, potentially leading to airway obstruction. These complications require immediate medical attention, including the administration of epinephrine and other interventions to stabilize the client.
A nurse notes that a 10-month-old infant has a larger head circumference than chest. The nurse interprets this as a normal finding because the head and chest circumference become equal at which age?
- A. 1 month
- B. 6 to 9 months
- C. 1 to 2 years
- D. to 3 years
Correct Answer: B
Rationale: It is considered normal for a baby's head circumference to be larger than their chest circumference during the first few months of life. Generally, a baby's head grows more rapidly than their chest, which causes the head circumference to be larger. By around 6 to 9 months of age, the head and chest circumference measurements typically become equal. This is part of the normal growth and development pattern in infants.
After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should highest priority to which intervention?
- A. Serving small portions bland food
- B. Encouraging rhythmic breathing exercises
- C. Administering metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed
- D. Withholding fluids for the first 4 to 6 hours after chemotherapy administration
Correct Answer: C
Rationale: Administering metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed should be the highest priority intervention for a client experiencing nausea and vomiting after cancer chemotherapy. Metoclopramide is a commonly used antiemetic medication that helps to reduce nausea and vomiting by enhancing gastric emptying and decreasing nausea. Dexamethasone, a corticosteroid, can also help alleviate inflammation that may contribute to the nausea and vomiting. By administering these medications as prescribed, the nurse can effectively address the client's symptoms and improve their comfort level. The other options, such as serving small portions bland food, encouraging rhythmic breathing exercises, and withholding fluids, are important interventions but should not take precedence over providing the prescribed antiemetic medications to manage the client's post-chemotherapy symptoms.
A baby is born precipitously in the ER. The nurses initial action should be to:
- A. Establish an airway for the baby
- B. Ascertain the condition of the fundus
- C. Quickly tie and cut the umbilical cord
- D. Move mother and baby to the birthing unit
Correct Answer: A
Rationale: The initial action that the nurses should take after a baby is born precipitously in the ER is to establish an airway for the baby. This is crucial for ensuring the baby's ability to breathe properly and for their overall well-being. Clearing the airway helps prevent complications such as asphyxia and ensures that the baby is receiving adequate oxygen. Once the airway has been established and the baby's breathing is stable, then other assessments and actions can be taken.
A patient was diagnosed with hiatal hernia. She frequently has regurgitation and a sour taste on his mouth especially after eating large meals. Which action by the client shows understanding of her treatment regimen?
- A. elevate her legs when she is sleeping
- B. drink more fluids with her meals
- C. increase the roughage in her diet
- D. avoid caffeine, alcohol, and chocolate
Correct Answer: D
Rationale: Hiatal hernia is a condition where a part of the stomach pushes up through the diaphragm muscle. Symptoms often include regurgitation of stomach acid into the esophagus, leading to heartburn and a sour taste in the mouth. Avoiding triggers like caffeine, alcohol, and chocolate can help reduce acid reflux and alleviate symptoms. These substances can relax the lower esophageal sphincter and increase stomach acid production, worsening symptoms in patients with hiatal hernia. Therefore, avoiding caffeine, alcohol, and chocolate is a key aspect of managing hiatal hernia symptoms effectively. The other options provided do not directly address the underlying cause of the symptoms experienced by the patient with hiatal hernia.