Nokea
Nursing measures in hemodynamic monitoring include assessing for localized ischemia owing to inadequate arterial flow. The nurse should:
- A. Assess the involved extremity for color and temperature
- B. Check for capillary refill
- C. Evaluate pulse rate
- D. Do all of the above
Correct Answer: D
Rationale: When assessing for localized ischemia owing to inadequate arterial flow, it is important for the nurse to perform all of the mentioned actions:
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What is the Guthrie blood test use to diagnose in the newborn?
- A. Down syndrome
- B. Isoimmunization
- C. PKU
- D. Congenital hypothyroidism (CH)
Correct Answer: C
Rationale: The Guthrie blood test, also known as the newborn screening test, is used to diagnose phenylketonuria (PKU) in newborns. PKU is an inherited metabolic disorder in which the body cannot properly process the amino acid phenylalanine. If left untreated, PKU can lead to intellectual disabilities and other serious health problems. The Guthrie blood test is a simple and effective way to detect PKU early so that treatment can begin promptly to prevent complications.
Which defect results in increased pulmonary blood flow?
- A. Pulmonic stenosis
- B. Tricuspid atresia
- C. Atrial septal defect
- D. Transposition of the great arteries
Correct Answer: C
Rationale: Atrial septal defect (ASD) is a congenital heart defect where there is an abnormal opening in the atrial septum, leading to a left-to-right shunt of blood. This shunt causes increased pulmonary blood flow, as oxygenated blood from the left atrium is shunted back into the right atrium and then into the pulmonary circulation. Over time, this increased pulmonary blood flow can lead to pulmonary hypertension and potentially Eisenmenger syndrome if left untreated. Pulmonic stenosis, tricuspid atresia, and transposition of the great arteries all typically result in decreased pulmonary blood flow rather than increased pulmonary blood flow.
Between 2-6 months of life, all are true about infant sleep EXCEPT
- A. total sleep hours are about 14-16 hr/24 hr
- B. sleeps about 9-10 hr concentrated at night
- C. sleeps 2 naps/day
- D. the sleep cycle time is similar to that of adults
Correct Answer: D
Rationale: Infant sleep cycles are shorter and differ from adult patterns.
Which of the following positions would be most appropriate for a patient with right-sided paralysis following a stroke?
- A. On the side with support to the back, with pillows to keep the body in alignment, hips slightly flexed, and hands tightly holding a rolled washcloth.
- B. On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
- C. On the back with two large pillows under the head, pillow under" the knees, and a footboard.
- D. On the back with no pillows used, with trochanter rolls and a footboard.
Correct Answer: B
Rationale: The most appropriate position for a patient with right-sided paralysis following a stroke is Option B - On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
A patient was rushed to the ER because of difficulty in urination. He was diagnosed then as a cse of benign prostate hyperthropy (BPH) and was advised by the doctor to undego transurethral resection of prostate (TURP). Based on the urgency of the surgery, the nurse classifies this condition as:
- A. emergency
- B. C.urgent
- C. elective
- D. required
Correct Answer: B
Rationale: Transurethral resection of prostate (TURP) is a surgical procedure commonly performed to treat benign prostatic hyperplasia (BPH) that is causing significant symptoms such as difficulty urinating. In this case, the patient was rushed to the ER due to the difficulty in urination, which indicates that the condition is causing acute distress and requires prompt intervention. Since the surgery was advised urgently by the doctor, the nurse classifies this condition as urgent. An urgent procedure is one that is necessary within a relatively short time frame to prevent complications or alleviate acute distress, but it is not an emergency that requires immediate intervention.