Nokea
The following contribute to the natural immunity transmitted in breast milk:
- A. Macrophages
- B. Natural killer cells
- C. Lysozyme
- D. Secretory IgA
Correct Answer: D
Rationale: Secretory IgA in breast milk plays a crucial role in providing passive immunity to the infant by protecting mucosal surfaces from pathogens.
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Aspirin has been ordered for the child with rheumatic fever (RF) in order to:
- A. Keep the patent ductus arteriosus (PDA) open
- B. Reduce joint inflammation
- C. Decrease swelling of strawberry tongue
- D. Treat ventricular hypertrophy of endocarditis
Correct Answer: B
Rationale: Aspirin helps alleviate the joint inflammation and pain experienced in RF.
A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?
- A. Increase the daily intake of oral fluids to liquefy secretions
- B. Avoid crowded enclosed areas to reduce pathogen exposure
- C. Call the clinic if undesirable side effects of mediations occur
- D. Teach anxiety reduction methods for feelings of suffocation
Correct Answer: A
Rationale: Increasing fluid intake helps to thin secretions, making them easier to expectorate and improving airway clearance.
A 16-year-old being treated for hypertension has laboratory values of: Hemoglobin: 16 g/dL Hematocrit: 43% Sodium: 139 mEq/L Potassium: 4.4 mEq/L Total cholesterol: 220 mg/dL Which drug does the nurse suspect the patient takes based on the total cholesterol?
- A. Beta blockers
- B. Calcium channel blockers
- C. ACE inhibitors
- D. Diuretics
Correct Answer: A
Rationale: Beta blockers are used with caution in patients with hyperlipidemia, hyperglycemia, and impotence.
A 5-month-old previously well infant is found to have a loud holosystolic murmur (4/6) at the left sternal border. The first and second heart sounds are normal; there is no tachycardia, rumble, or gallop; and hepatomegaly is not noted. The child feeds well and has grown adequately. You suspect
- A. spontaneous closure is more common in muscular vs. membranous defects
- B. closure usually occurs in the first 2 years of life
- C. there is no risk of endocarditis
- D. pulmonary pressures are normal
Correct Answer: C
Rationale: Small VSDs still carry a risk of endocarditis despite being asymptomatic.
When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?
- A. Daily weight
- B. Vital signs
- C. Level of consciousness
- D. Bowel sounds
Correct Answer: A
Rationale: Daily weight is crucial in monitoring fluid balance in clients with nephrotic syndrome, as they are prone to edema.