Nokea
The birthweight usually quadruples by the age of
- A. 1.5 years
- B. 2 years
- C. 2.5 years
- D. 3 years
Correct Answer: B
Rationale: Birthweight typically quadruples by 2 years.
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An adult has a central venous line. Which of the following should the nurse include in the plan of care?
- A. Complete blood count and electrolytes
- B. Regular chest x rays to ensure proper placement of the central line
- C. Continuous infusion of the solution at a keep vein open rate
- D. Any signs of infection, air embolus, and leakage or puncture
Correct Answer: D
Rationale: An adult with a central venous line should include monitoring for any signs of infection, air embolus, and leakage or puncture in the plan of care. Central venous lines carry a risk of complications such as infection, air embolism, and mechanical issues like leakage or puncture. These complications can be serious and require immediate attention to prevent further harm to the patient. Regular monitoring and assessment for these potential issues are crucial in providing safe care for a patient with a central venous line. Other options (A, B, C) may be important in the overall care but monitoring for complications is the priority.
A nurse approaches a hospitalized poststroke patient from the patient's left side to do an assessment. The patient is staring straight ahead, and does not respond to the nurse's presence or voice. Which action should the nurse take first?
- A. Walk to the other side of the bed and try again
- B. Speak more loudly and clearly
- C. Wave his or her fingers in front of the patient's face
- D. Use a picture to explain to the patient what the nurse is going to do.
Correct Answer: A
Rationale: The nurse should walk to the other side of the bed and approach the patient from the right side. Poststroke patients may have neglect syndrome, which can cause them to ignore stimuli on one side of their body. By approaching from the neglected side (the right side in this case), the nurse may be able to better capture the patient's attention and engage them in the assessment process. It is essential to adapt care to accommodate the patient's condition and ensure effective communication and interaction.
The developmental age of a child who continues to search for a hidden subject has achieved
- A. 7 months
- B. 9 months
- C. 11 months
- D. 13 months
Correct Answer: B
Rationale: Object permanence is typically achieved around 9 months.
When caring for a 3 year old with tetralogy of Fallot, he nurse expects to see fatigue and poor activity tolerance. This is caused by:
- A. Poor muscle tone
- B. Inadequate oxygenation of tissues.
- C. Restricted blood flow leaving the heart
- D. Inadequate intake of food.
Correct Answer: B
Rationale: Tetralogy of Fallot is a heart defect that involves four specific abnormalities in the heart's structure. One of these abnormalities is a ventricular septal defect, which results in a mixing of oxygenated and deoxygenated blood. This leads to inadequate oxygenation of tissues because some of the blood that is pumped out to the body is not fully oxygenated. As a result, the child may experience fatigue and poor activity tolerance due to the reduced oxygen supply to the tissues and organs. This is why the nurse would expect to see these symptoms in a 3-year-old with tetralogy of Fallot.
Which of the following is one of the discharge criteria from ambulatory surgery for patients following surgery?
- A. Able to drive self home
- B. IV narcotics given less than 30 minutes
- C. Has home telephone before discharge
- D. Understands discharge instructions
Correct Answer: D
Rationale: Understanding discharge instructions is one of the key criteria for discharging patients following surgery in an ambulatory setting. It ensures that the patient comprehends how to care for themselves post-surgery and reduces the risk of complications or the need for readmission. While the other options may also be important factors, having a clear understanding of discharge instructions is crucial for the patient's recovery and overall well-being.