Nokea
In addition to weakness and fatigue, which of the following problems should the nurse expect Aisa to exhibit?
- A. Elevated blood pressure
- B. Increased pulse rate
- C. Cyanosis of the nail beds
Correct Answer: B
Rationale: In addition to weakness and fatigue, the nurse should expect Aisa to exhibit an increased pulse rate. Weakness and fatigue are common symptoms of anemia, a condition characterized by a decrease in the number of red blood cells or hemoglobin in the blood. Anemia can lead to the heart working harder to pump oxygen-rich blood to the body, resulting in an increased pulse rate. Therefore, it is important for the nurse to assess for signs of tachycardia (elevated heart rate) in a patient with anemia.
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About 500 children have just been exposed to radiation from a nuclear power plant accident. The most appropriate first step in your treatment of these children should be to
- A. prescribe potassium iodide to protect the thyroid
- B. order thyroid function tests
- C. order complete blood counts (CBCs)
- D. do nothing acutely; evaluate in 4-6 weeks
Correct Answer: A
Rationale: Potassium iodide can protect the thyroid from radioactive iodine exposure, which is a critical first step in radiation exposure.
Which gauge IV cannula should the nurse choose when preparing to initiate a blood transfusion?
- A. 18
- B. 24
- C. 22
- D. 28
Correct Answer: A
Rationale: An 18-gauge IV cannula is the most appropriate choice when preparing to initiate a blood transfusion. This larger size allows for the rapid administration of blood products, which is important to prevent clotting and ensure a stable flow of the transfusion. Smaller gauge sizes, such as 22, 24, or 28, may be too slow for transfusion purposes and could potentially lead to delays or complications during the procedure. Therefore, the optimal choice for initiating a blood transfusion is an 18-gauge IV cannula.
A nurse is planning care for a preterm newborn. Which interventions should the nurse implement for skin care? (Select all that apply.)
- A. Use cleaning agents with neutral pH.
- B. Rub skin during drying.
- C. Use adhesive remover solvent when removing tape.
- D. Avoid removing adhesives for at least 24 hours.
Correct Answer: A
Rationale: Using cleaning agents with neutral pH is important for the delicate skin of a preterm newborn to prevent irritation and damage.
An adult has been stung by a bee and is in anaphylactic shock. An epinephrine (adrenaline) injection has been given. The nurse would expect which the following if the injection has been effective?
- A. The client's breathing will become easier
- B. The client's blood pressure will decrease
- C. There will be an increase in angiodema
- D. There will be a decrease in the client's level of consciousness
Correct Answer: A
Rationale: An epinephrine (adrenaline) injection is the first-line treatment for anaphylaxis, as it helps to relax the muscles in the airway and improve breathing. This results in the client's breathing becoming easier. Epinephrine also acts to increase blood pressure, while angioedema (swelling) and a decreased level of consciousness are not expected effects of an effective epinephrine injection.
Which of the following measures will not help correct the patient's condition
- A. Offer large amount of oral fluid intake to replace fluid lost
- B. Give enteral or parenteral fluid
- C. Frequent oral care
- D. Give small volumes of fluid at frequent interval
Correct Answer: C
Rationale: Frequent oral care is important for overall oral health and cleanliness, but it will not directly help correct the patient's fluid imbalance. The patient's condition likely requires direct fluid replacement to address the fluid loss and restore balance. A, B, and D are focused on fluid replacement strategies which are more crucial in correcting the patient's condition. Offering a large amount of oral fluid intake to replace lost fluids, giving enteral or parenteral fluid, and giving small volumes of fluid at frequent intervals are all appropriate measures that can help correct the patient's condition by addressing the underlying fluid imbalance.