Nokea
The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
- A. Serum potassium level of 4.9mEq/L
- B. Temperature of 99.2F (37.3C)
- C. Serum sodium level of 135mEq/L
- D. Urine output of 20mL/hour
Correct Answer: D
Rationale: A low urine output of 20mL/hour shortly after kidney transplant surgery is a critical finding that must be reported to the physician immediately. Adequate urine output is essential to ensure proper kidney function and the body's ability to eliminate waste products and regulate electrolyte levels. A urine output of less than 30mL/hour is considered oliguria, which may indicate decreased kidney function or potential complications such as acute kidney injury. Therefore, prompt evaluation and intervention are necessary to prevent further kidney damage or complications in the client.
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A client diagnosed with DIC is ordered heparin. What is the reason for this medication?
- A. Prevent clot formation
- B. Increase clot formation
- C. Increased blood flow to target organs
- D. Decrease blood flow to target organs
Correct Answer: A
Rationale: Heparin is a medication commonly used to prevent clot formation in various clinical conditions, including Disseminated Intravascular Coagulation (DIC). DIC is a serious condition characterized by abnormal blood clotting and bleeding throughout the body. Heparin works by inhibiting the formation of new clots and preventing the existing clots from further growing, thus helping to manage and prevent complications associated with DIC. By using heparin, the aim is to help stabilize the patient's clotting process and reduce the risk of severe complications such as organ damage or failure.
The nurse should expect a client with hypothyroidism to report which health concerns?
- A. Increased appetite and weight loss
- B. Nervousness and tremors
- C. Puffiness of the face and hands
- D. Thyroid gland swelling
Correct Answer: C
Rationale: Hypothyroidism is characterized by an underactive thyroid gland that does not produce enough thyroid hormone. This hormonal imbalance can lead to symptoms such as slow metabolism, weight gain, fatigue, cold intolerance, constipation, and puffiness of the face and hands. The slowed metabolic rate can also cause fluid retention, resulting in the characteristic puffiness associated with hypothyroidism. Increased appetite and weight loss are not typical symptoms of hypothyroidism, as the condition is more commonly associated with weight gain. Nervousness and tremors are more indicative of hyperthyroidism, where the thyroid gland is overactive. Thyroid gland swelling, known as goiter, can occur in various thyroid disorders but is not specific to hypothyroidism.
On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life- threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
- A. Hypocalcemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypermagnesemia
Correct Answer: A
Rationale: Hypocalcemia is the most common electrolyte disturbance that follows thyroid surgery, particularly after a partial thyroidectomy. This occurs due to inadvertent injury or removal of the parathyroid glands, which are responsible for regulating calcium levels in the body. The symptoms of hypocalcemia, such as muscle twitching, hyperirritability of the nervous system, numbness, and tingling, align with the client's presentation in this scenario. Prompt recognition and treatment of hypocalcemia are crucial to prevent life-threatening complications like tetany or seizures. Therefore, the nurse's decision to notify the surgeon immediately is appropriate to address this electrolyte imbalance.
Immunization of children with Haemophilus influenzae type B (Hib) vaccine decreases the incidence of which of the following conditions?
- A. Bronchiolitis
- B. Laryngotracheobronchitis (LTB)
- C. Epiglottitis
- D. Pneumonia
Correct Answer: C
Rationale: Immunization of children with Haemophilus influenzae type B (Hib) vaccine decreases the incidence of severe infections caused by Haemophilus influenzae type B bacteria, including epiglottitis. Epiglottitis is a serious condition where the epiglottis, a flap of tissue that sits at the base of the tongue, becomes inflamed and can swell, potentially blocking the airway and leading to respiratory distress and even death. By vaccinating children against Hib, the risk of developing epiglottitis is significantly reduced. The Hib vaccine is a crucial component of childhood immunization programs to prevent life-threatening diseases caused by Hib bacteria, including epiglottitis.
ahmed 2 months old come to emergency department with epistaxis and prolong PTT, clotting and bleeding time , what you suspect ahmed have :
- A. thalassemia
- B. hemophilia
- C. leukemia
- D. sickle anemia
Correct Answer: B
Rationale: Ahmed is presenting with epistaxis (nosebleed) and prolonged PTT (partial thromboplastin time), clotting time, and bleeding time, which are indicative of a bleeding disorder. Given the symptoms and lab findings, hemophilia is the most likely cause. Hemophilia is an inherited bleeding disorder characterized by deficiency or dysfunction of clotting factors, particularly Factor VIII (hemophilia A) or Factor IX (hemophilia B). Patients with hemophilia often present with spontaneous bleeding episodes, such as nosebleeds, bruising, and prolonged bleeding after injury or surgery. Thalassemia, leukemia, and sickle cell anemia are not associated with prolonged clotting times and bleeding presentations, making hemophilia the most appropriate choice in this scenario.