Nokea
In embryonic period, all are true EXCEPT
- A. formation of ectoderm by 8 days
- B. formation of mesoderm by 10 weeks
- C. formation of endoderm by 3 cm crown-rump length
- D. formation of human embryo is about 6 weeks
Correct Answer: D
Rationale: The formation of the human embryo is completed by 8 weeks, not 6 weeks.
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An adult has a Hickman type central venous catheter and needs to have blood drawn from it. Which of the following should the nurse do first?
- A. Use sterile technique to assemble supplies needed
- B. Aspirate and discard the first 10 ml of the blood
- C. First flush the catheter with heparinized solution, then withdraw the blood
- D. Remove the cap of the catheter and replace it with a new one
Correct Answer: C
Rationale: Before drawing blood from a central venous catheter like a Hickman type, it is essential to ensure that the catheter is patent and free of any clots. Flushing the catheter with a heparinized solution (to prevent clot formation) before withdrawing blood helps clear the catheter and ensures accurate blood sample collection. Removing clots or obstructions from the catheter is crucial to prevent complications and maintain the catheter's function. Therefore, it is important to first flush the catheter with a heparinized solution before drawing blood from it.
The stump of the umbilical cord usually separates in how many days?
- A. 3
- B. 10 to 14
- C. 16 to 20
- D. 28
Correct Answer: B
Rationale: The stump of the umbilical cord usually separates from the baby's belly button within 10 to 14 days after birth. During this time, it is important to keep the area clean and dry to prevent infection. Once the stump falls off, a small open wound may be left behind, which should also be kept clean and dry until it completely heals. It is normal for a small amount of blood or discharge to be present during this process, but if there are signs of infection such as redness, swelling, or foul odor, it is important to contact a healthcare provider for further evaluation and treatment.
The nurse is developing a plan of care for marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable?
- A. 24 hours
- B. 7 to 14 days
- C. 2 to 4 days
- D. 21 to 28 days
Correct Answer: C
Rationale: Marrow suppression is the major dose-limiting adverse reaction to floxuridine (FUDR). It typically becomes noticeable 2 to 4 days after drug administration. Floxuridine acts by interfering with DNA replication and is most toxic to rapidly dividing cells, such as those in the bone marrow. As a result, bone marrow suppression leading to decreased production of blood cells can occur relatively quickly after the administration of floxuridine. Monitoring for bone marrow suppression is essential in patients receiving this medication to ensure timely intervention and prevention of complications such as anemia, thrombocytopenia, and leukopenia.
Which of the ff. nursing actions is most appropriate when doing perineal care on an uncircumcised male patient?
- A. Leave the foreskin retracted so air can keep the area dry
- B. Do not retract the foreskin during washing
- C. Replace the foreskin over the head of the penis after washing
- D. Use alcohol and a cotton swab to clean under the foreskin
Correct Answer: C
Rationale: When performing perineal care on an uncircumcised male patient, it is important to replace the foreskin over the head of the penis after washing. The foreskin should not be left retracted or pulled back forcibly as it can cause irritation and discomfort to the patient. Leaving the foreskin retracted can also lead to potential complications such as paraphimosis, where the foreskin becomes trapped behind the head of the penis. Proper hygiene involves gently retracting the foreskin to clean underneath it and then returning it to its natural position to protect the sensitive glans penis. Using gentle, warm water with mild soap is typically sufficient for cleaning, and alcohol should be avoided as it can cause irritation and dryness to the sensitive genital area.
The nurse is caring for an adolescent brought to the hospital with acute drug toxicity. Cocaine is believed to be the drug involved. Data collection should include what information?
- A. Mode of administration
- B. Drug's actual content
- C. Function the drug plays in the adolescent's life
- D. Adolescent's level of interest in rehabilitation
Correct Answer: A
Rationale: When caring for an adolescent with acute drug toxicity, it is important to gather information on the mode of administration of the drug to understand how it was taken into the body. This information can help the healthcare team determine the extent of drug exposure, potential complications, and appropriate treatment strategies. The mode of administration can include ingestion, inhalation, injection, or other routes, and each method may have different implications for the patient's condition. Understanding how the drug was administered is crucial in managing the adolescent's care effectively.