Nokea
Recognised features of ABO incompatibility include:
- A. Normal haemoglobin on day 1
- B. Worsening with subsequent pregnancies
- C. Conjugated hyperbilirubinaemia
- D. Negative Coombs test
Correct Answer: A
Rationale: In ABO incompatibility, haemoglobin levels are typically normal on day 1. The condition does not worsen with subsequent pregnancies and is associated with unconjugated hyperbilirubinaemia.
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A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on the heart tones heard?
- A. Administer a diuretic.
- B. Document the finding.
- C. Decrease the IV flow rate.
- D. Evaluate the client’s medications.
Correct Answer: B
Rationale: Documenting the findings is the appropriate action unless the heart tones indicate an abnormality requiring intervention.
A child has been seen by the school nurse for dizziness since the start of the school term. It happens when standing in line for recess and homeroom. The child now reports that she would rather sit and watch her friends play hopscotch because she cannot count out loud and jump at the same time. When the nurse asks her if her chest ever hurts, she says yes. Based on this history, the nurse suspects that she has:
- A. Ventricular septal defect (VSD)
- B. Aortic stenosis (AS)
- C. Mitral valve prolapse
- D. Tricuspid atresia
Correct Answer: B
Rationale: AS can progress and result in exercise intolerance, which may improve with rest.
What are TWO possible interventions for an infant with Tetralogy of Fallot who has recurrent desaturation episodes on propranolol?
- A. Full surgical repair
- B. Interim repair with RVOT stent or shunt
- C. Propranolol dose adjustment
- D. All of the above
Correct Answer: B
Rationale: Interim repair with RVOT stent or shunt can be used to improve oxygenation in infants who are not candidates for immediate full surgical repair.
Regarding body iron stores:
- A. Serum ferritin is a poor guide to iron stores
- B. A healthy young man will have more iron stored as ferritin than in the circulating red cell mass
- C. Iron is the stimulant for ferritin production
- D. In iron deficiency, stores of haemosiderin are mobilised before ferritin
Correct Answer: C
Rationale: Iron is a key regulator for ferritin production, and as iron levels rise, ferritin synthesis is stimulated to store excess iron.
A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?
- A. Obtain oxygen saturation level
- B. Encourage incentive spirometry
- C. Assess lower extremity circulation
- D. Administer PRN oral antipyretic
Correct Answer: D
Rationale: Administering an antipyretic addresses the fever, which is a priority in this client to prevent further complications.