Nokea
The child who can hop on one foot, copies circles, and brushes teeth without help has achieved the developmental age of
- A. 2 yr
- B. 3 yr
- C. 4 yr
- D. 5 yr
Correct Answer: B
Rationale: These skills are typically developed by age 3.
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Baby Melody is a neonate who has a very low-birth-weight. Nurse Josie carefully monitors inspiratory pressure and oxygen (O ) concentration to prevent which of the following?
- A. Meconium aspiration syndrome
- B. Bronchopulmonary dysplasia (BPD)
- C. Respiratory syncytial virus (RSV)
- D. Respiratory distress syndrome (RDS)
Correct Answer: D
Rationale: A neonate with very low birth weight is at risk of developing respiratory distress syndrome (RDS), which is a common breathing disorder in premature infants. RDS occurs due to a lack of a substance in the lungs called surfactant, which helps keep the air sacs open and prevents them from collapsing. In neonates with very low birth weight, the lungs may not have produced enough surfactant, leading to breathing difficulties and respiratory distress.
A child is to receive a blood transfusion, if an allergic reaction to the blood occurs, the nurse's first intervention should be:
- A. Relieved the symptoms with an ordered
- B. Slow the flow rate antihistamines
- C. Stop the blood immediately
Correct Answer: C
Rationale: In the scenario of a child experiencing an allergic reaction during a blood transfusion, the nurse's first intervention should always be to stop the blood immediately. This is crucial to prevent further complications and adverse reactions in the child. Pausing the transfusion allows for assessment of the allergic reaction's severity, immediate treatment initiation, and alerting the healthcare team for further management. Relieving symptoms with antihistamines or slowing the flow rate would not address the primary concern of stopping the allergen from entering the child's system. Therefore, stopping the blood immediately is the most appropriate and urgent action to take in this situation.
Which of these signs suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?
- A. Tetanic contractions
- B. Weight loss
- C. Neck vein distention
- D. Polyuria
Correct Answer: C
Rationale: In the context of syndrome of inappropriate antidiuretic hormone (SIADH), complications such as hyponatremia and fluid overload can lead to increased volume in the venous system, including the neck veins. Neck vein distention is a sign associated with fluid overload and can be indicative of worsening complications in a client with SIADH. Tetanic contractions are not typical manifestations of complications in SIADH. Weight loss and polyuria are not commonly associated with SIADH due to the increased water retention caused by the syndrome.
To treat cervical cancer, a client has had an applicator of radioactive material placed in the vagina. Which observation by the nurse indicates a radiation hazard?
- A. The client is maintained on strict bed rest
- B. The head of the bed is at 30-degree angle
- C. The client receives a complete bed bath each morning
- D. The nurse checks the applicator's position every 4 hours
Correct Answer: B
Rationale: Keeping the head of the bed at a 30-degree angle can dislodge the applicator of radioactive material placed in the vagina. When caring for a client with a radioactive applicator, it is important to ensure that the position of the applicator is maintained to prevent radiation exposure to staff and other clients. This can be achieved by keeping the head of the bed flat without elevation. The other options are appropriate measures in caring for a client with a radioactive applicator.
Which of the following complications can occur if a clotted cannula is aggressively flushed?
- A. A clot can enter the circulation.
- B. An air embolism can enter the circulation.
- C. A painful arterial spasm can occur.
- D. Fluid extravasation into surrounding tissue can occur.
Correct Answer: A
Rationale: If a clotted cannula is aggressively flushed, there is a risk that the clot may break apart and enter the circulation. This can lead to serious complications such as embolism, where the clot travels through the blood vessels and blocks blood flow to vital organs. It is important to handle clotted cannulas with care to prevent such complications from occurring.