Nokea
Mr. Go had a post-kidney transplant. What should the nurse immediately assess?
- A. fluid and electrolyte imbalances
- B. hepatotoxicity
- C. infection
- D. respiratory complications
Correct Answer: A
Rationale: After a kidney transplant, it is essential for the nurse to immediately assess for fluid and electrolyte imbalances in the recipient. The transplanted kidney may take some time to start functioning optimally, and during this period, the body may not be able to regulate fluid and electrolyte balance effectively. Monitoring for signs of fluid overload, electrolyte disturbances, and kidney function is crucial to prevent complications such as dehydration, electrolyte abnormalities, and organ rejection. Early detection of these imbalances allows for prompt intervention and prevention of potential complications.
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While caring for a critically ill child, the nurse observes that respirations are gradually increasing in rate and depth, with periods of apnea. What pattern of respiration will the nurse document?
- A. Dyspnea
- B. Tachypnea
- C. Cheyne-Stokes respirations
- D. Seesaw (paradoxic) respirations
Correct Answer: C
Rationale: Cheyne-Stokes respirations are characterized by alternating periods of deep, rapid breathing followed by periods of apnea. This cyclic pattern of respiration is often seen in critically ill patients and can be a sign of serious neurological or cardiac dysfunction. The nurse should document Cheyne-Stokes respirations when observing this specific breathing pattern in the child described in the scenario.
In terms of fine motor development, what should the infant of 7 months be able to do?
- A. Transfer objects from one hand to the other and bang cubes on a table.
- B. Use thumb and index finger in crude pincer grasp and release an object at will.
- C. Hold a crayon between the fingers and make a mark on paper.
- D. Release cubes into a cup and build a tower of two blocks.
Correct Answer: A
Rationale: At 7 months old, infants are typically able to transfer objects from one hand to the other and bang cubes on a table. This demonstrates the development of their fine motor skills related to coordination, dexterity, and object manipulation. They are refining their hand-eye coordination and grasping abilities at this stage, preparing for more complex fine motor tasks in the future. The ability to purposefully transfer objects between hands and make intentional actions, like banging cubes on a table, shows the progression of their fine motor development at this age.
When should the nurse expect jaundice to be present in a newborn with hemolytic disease?
- A. At birth
- B. During first 24 hours after birth
- C. 24 to 48 hours after birth
- D. 48 to 72 hours after birth
Correct Answer: D
Rationale: In a newborn with hemolytic disease, jaundice typically appears 48 to 72 hours after birth due to the accumulation of bilirubin in the baby's blood. This condition is known as hyperbilirubinemia, which occurs when the liver is still immature and unable to effectively process bilirubin. The breakdown of red blood cells in hemolytic disease leads to an increased production of bilirubin, resulting in jaundice. It is important for healthcare providers to monitor the newborn closely during this time period to ensure appropriate management of the jaundice.
The nurse is explaining the action of insulin to a newly diagnosed diabetic client. During the teaching, the nurse reviews the process of insulin secretion in the body. The nurse is correct when stating that insulin is secreted from the:
- A. adenohypohysis.
- B. alpha cells of the pancreas.
- C. beta cells of the pancreas.
- D. parafollicular cells of the thyroid.
Correct Answer: C
Rationale: Insulin is secreted from the beta cells of the pancreas. These specialized cells are located in the islets of Langerhans within the pancreas. When blood glucose levels rise after eating, beta cells release insulin into the bloodstream to help regulate glucose levels by allowing cells to take in glucose for energy or storage. Insulin also helps lower blood sugar by promoting the conversion of glucose to glycogen in the liver and muscles. Therefore, the nurse is correct in stating that insulin is secreted from the beta cells of the pancreas.
Seventy-two hours after cardiac surgery, a young child has a temperature of 101° F. Which action should the nurse take?
- A. Keep child warm with blankets.
- B. Apply a hypothermia blanket.
- C. Record temperature on nurses' notes.
- D. Report findings to physician.
Correct Answer: D
Rationale: A temperature of 101°F after cardiac surgery in a young child, especially 72 hours post-surgery, is a concerning finding that should be reported to the physician. This elevated temperature could indicate infection or another complication following the surgery. It is important for the physician to evaluate the child's condition and determine the appropriate course of action. Simply recording the temperature on nurses' notes or keeping the child warm with blankets is not adequate management in this situation. Applying a hypothermia blanket would also not be appropriate as the child is already febrile. The priority in this scenario is to report the findings to the physician for further assessment and intervention.