Nokea
If a Wall unit is used, What should be the suctioning pressure required by James?
- A. 50-95 mmHg
- B. 100-120 mmHg
- C. 95-110 mmHg
- D. 155-175 mmHg
Correct Answer: A
Rationale: The recommended suction pressure range for suctioning an adult patient using a wall unit is typically between 80-120 mmHg. However, for a pediatric patient, the recommended suction pressure range is lower, usually between 50-95 mmHg. In this case, James' age is specified, so it is crucial to consider the appropriate suction pressure range for pediatric patients. Therefore, the suctioning pressure required by James should be in the range of 50-95 mmHg, making option A the correct answer.
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An elderly client develops severe bone marrow depression from chemotheraphy for cancer of the prostate. The nurse should;
- A. Monitor Intake and output of fluids
- B. Increase dally intake of fluids
- C. Use a soft toothbrush for oral hygiene HEMATOPOIETIC AND LYMPHATIC SYSTEMS
Correct Answer: A
Rationale: Monitoring intake and output of fluids is essential for an elderly client who develops severe bone marrow depression from chemotherapy for prostate cancer. Bone marrow depression can result in decreased production of blood cells, including red blood cells, white blood cells, and platelets. Monitoring intake and output of fluids helps assess hydration status and kidney function. Decreased fluid intake or output may indicate kidney damage or dehydration, which are common concerns in clients with bone marrow depression. Therefore, it is crucial for the nurse to monitor the client's fluid balance closely to ensure optimal functioning of the kidneys and prevent complications related to bone marrow suppression.
When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea and itching. When urticarial, tachycardia, and hypotension develop, the nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction?
- A. Type I (immediate, anaphylactic) hypersensitivity reaction
- B. Type II (cytolytic, cytotoxic) hypersensitivity reaction
- C. Type III (immune complex) hypersensitivity reaction
- D. Type IV (cell-mediated, delayed) hypersensitivity reaction
Correct Answer: A
Rationale: The symptoms described in the scenario, such as chest pain, nausea, itching, urticaria, tachycardia, and hypotension, are indicative of an immediate hypersensitivity reaction, also known as a Type I hypersensitivity reaction. This type of reaction is triggered by the release of histamine and other inflammatory mediators from mast cells and basophils. Symptoms can range from mild to severe and can manifest rapidly after exposure to the allergen, in this case, the blood transfusion. Common manifestations include skin reactions (e.g., itching, urticaria), respiratory symptoms (e.g., chest pain, wheezing), cardiovascular changes (e.g., tachycardia, hypotension), and gastrointestinal symptoms (e.g., nausea, vomiting).
Parents of a newborn ask the nurse why vitamin K is being administered. The nurse accurately responds by explaining phytonadione (vitamin K) is administered to the newborn to:
- A. prevent bleeding.
- B. enhance immune response.
- C. prevent bacterial infection.
- D. maintain nutritional status.
Correct Answer: A
Rationale: Vitamin K is essential for the production of clotting factors in the liver. Newborns have lower levels of vitamin K and may not have a fully functioning clotting system, putting them at risk for bleeding disorders such as vitamin K deficiency bleeding (VKDB). Administering vitamin K to newborns helps prevent these bleeding issues and ensures proper clotting function. It does not have a direct effect on enhancing the immune response, preventing bacterial infections, or maintaining nutritional status, as its primary function in this context is to prevent bleeding disorders.
Which of the following is the most common symptoms of pericarditis?
- A. Dyspnea c.Chest pain
- B. Intermittent claudication
- C. Calf pain
Correct Answer: A
Rationale: The most common symptom of pericarditis is chest pain. This chest pain is typically sharp and stabbing, and it may worsen when taking deep breaths or lying down. It can also be relieved by sitting up or leaning forward. Other symptoms of pericarditis may include dyspnea (shortness of breath), but chest pain is the hallmark symptom that differentiates pericarditis from other conditions. Intermittent claudication and calf pain are not typically associated with pericarditis.
A post-TURP patient experiences dribbling following removal of his catheter. Which action should the nurse take?
- A. Have him restrict fluid intake to 1000 mL/day
- B. Teach him to perform Kegel's exercises 10 to 20 times per hour
- C. Reinsert the Foley catheter until he regains urinary control
- D. Reassure him that incontinence never lasts more than a few days
Correct Answer: B
Rationale: The best course of action for a post-TURP patient experiencing dribbling after catheter removal is to teach him to perform Kegel's exercises 10 to 20 times per hour. Kegel exercises help strengthen the pelvic floor muscles, which can improve urinary control and reduce dribbling. Restricting fluid intake is not recommended as it can lead to dehydration. Reinserting the Foley catheter is not ideal unless there are complications. Incontinence following TURP can take time to improve, so reassuring the patient that it never lasts more than a few days may give false expectations. Teaching Kegel exercises is the most appropriate intervention to address post-TURP dribbling.