Several hours after returning from surgery, the nurse tells the patient that she is ordered to be ambulated. The patient asks, "Why?" Which of the following complications would the nurse correctly explain can be prevented by early postoperative ambulation?
- A. Increased peristalsis
- B. Coughing
- C. Pneumonia
- D. Wound healing  A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET K
Correct Answer: C
Rationale: Early postoperative ambulation is important for preventing complications such as pneumonia. When a patient remains immobile for an extended period after surgery, they are at an increased risk of developing pneumonia due to decreased lung expansion and secretions pooling in the lungs. Ambulation helps improve lung function, promote better oxygenation, and prevent respiratory complications like pneumonia. In contrast, increased peristalsis helps prevent constipation, coughing helps prevent respiratory complications as well, and wound healing is not directly related to the need for early postoperative ambulation.
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A 6 months old boy presents with respiratory distress and feeding difficulty. On examination heart rate is 130/min and there is a pansystolic murmur at left lower sternal border. What is the most likely diagnosis?
- A. Mitral regurgitation
- B. Mitral valve prolapse
- C. Ventricular septal defect
- D. Coarctation of aorta
Correct Answer: C
Rationale: Ventricular septal defect (VSD) commonly presents with a pansystolic murmur and symptoms of congestive heart failure in infancy.
Which of the following statements about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?
- A. Administer 2 to 3L of IV fluid rapidly
- B. Administer 6L of IV fluid over the first 24 hours
- C. Administer a dextrose solution containing normal saline solution
- D. Administer IV fluid slowly to prevent circulatory overload and collapse
Correct Answer: B
Rationale: For a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS), the correct statement is to administer 6L of IV fluid over the first 24 hours (option B). The management of HHNS focuses on correcting dehydration and hyperglycemia. The initial fluid resuscitation in HHNS aims to address the profound dehydration that occurs due to osmotic diuresis from hyperglycemia. The recommended rate is to administer 1 to 1.5 L/hour of IV fluid until the patient is hemodynamically stable and urine output is adequate. Administering fluid rapidly helps to address the hypovolemia and prevent complications associated with shock. Administering fluid too slowly may delay the correction of dehydration and lead to further complications.
While examining a 2-year-old child, the nurse in charge sees that the anterior fontanel is open. The nurse should:
- A. Notify the doctor
- B. Look for other signs of abuse
- C. Recognize this as a normal finding
- D. Ask about a family history of Tay-Sachs disease
Correct Answer: C
Rationale: In infants and young children, it is normal for the anterior fontanel to remain open up to about 18-24 months of age. The fontanel serves an important function in allowing the skull to grow and expand as the brain grows rapidly during infancy. Therefore, the presence of an open fontanel in a 2-year-old child is a normal finding and does not warrant any immediate concern or action. It does not indicate abuse, the need to notify the doctor, or inquire about a family history of Tay-Sachs disease.
A patient is admitted with a 2-month history of fatigue, SOB, pallor, and dizziness. The patient is diagnosed with idiopathic autoimmune haemolytic anemia. On reviewing the laboratory results, the nurse notes which of the following that confirms this diagnosis?
- A. RBC fragments
- B. Microcytic, hypochromic RBCs
- C. Macrocytic, normochromic RBCs
- D. Hemoglobin molecules
Correct Answer: A
Rationale: In patients with idiopathic autoimmune hemolytic anemia, the immune system mistakenly targets and destroys its own red blood cells (RBCs). When the red blood cells are destroyed, they can break apart, leading to the presence of fragmented RBCs, also known as schistocytes or red cell fragments, in the peripheral blood. The presence of RBC fragments is a characteristic finding in this type of hemolytic anemia and helps confirm the diagnosis.
Which is a common childhood communicable disease that may cause severe defects in the fetus when it occurs in its congenital form?
- A. Erythema infectiosum
- B. Roseola
- C. Rubeola
- D. Rubella
Correct Answer: D
Rationale: Rubella is a common childhood communicable disease that can cause severe defects in the fetus when a pregnant woman contracts the infection, leading to congenital rubella syndrome. This syndrome can result in various abnormalities in the developing fetus, such as hearing loss, vision problems, heart defects, and intellectual disabilities. Rubella is particularly dangerous when contracted during the first trimester of pregnancy, leading to a higher risk of complications for the unborn child. Therefore, Rubella is a significant public health concern due to its potential impact on fetal development and the importance of vaccination to prevent its spread.