Nokea
The nurse is assessing a child with acute otitis media. Which finding should the nurse expect?
- A. Bilateral eye discharge and fever
- B. A bulging, red tympanic membrane
- C. Nasal congestion and headache
- D. Persistent cough and sore throat
Correct Answer: B
Rationale: Acute otitis media typically presents with a bulging, red tympanic membrane due to fluid accumulation and infection.
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A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The healthcare provider prescribes a nasogastric tube (NGT) to be inserted and placed to intermittent low wall suction. Which intervention should the nurse implement to facilitate proper tube placement?
- A. Soak nasogastric tube in warm water
- B. Insert tube with client's head tilted back
- C. Apply suction while inserting tube
- D. Elevate head of bed 60 to 90 degrees
Correct Answer: D
Rationale: Elevating the head of the bed helps facilitate proper placement of the NGT and reduces the risk of aspiration.
Which painful, tender, pea-sized nodules may appear on the pads of the fingers or toes in bacterial endocarditis?
- A. Osler nodes
- B. Janeway lesions
- C. Subcutaneous nodules
- D. Aschoff nodes
Correct Answer: A
Rationale: Osler nodes are red, painful, intradermal nodes found on pads of the phalanges in bacterial endocarditis. Janeway lesions are painless hemorrhagic areas on palms and soles in bacterial endocarditis. Subcutaneous odules are nontender swellings, located over bony prominences, commonly found in rheumatic fever. Aschoff nodules are small nodules composed of cells and leukocytes found in the interstitial tissues of the heart in rheumatic myocarditis
Triggers of the alternate pathway of complement are:
- A. Bacterial lipopolysaccharide
- B. Interleukin 2
- C. Macrophages
- D. Properdin
Correct Answer: A
Rationale: The correct answer is A because bacterial lipopolysaccharide is a known trigger of the alternate complement pathway. The other options (b-e) are not primary triggers.
Varying intensity of the first heart sound from a booming (bruit de canon) to virtual inaudibility is seen in which of the following?
- A. Mitral stenosis with atrial fibrillation
- B. Constant 2:1 AV block
- C. First-degree AV block
- D. Congenital complete heart block
Correct Answer: A
Rationale: In mitral stenosis with atrial fibrillation, the intensity of the first heart sound can vary depending on the dynamics of atrial contraction and ventricular filling.
Seventy-two hours after cardiac surgery, a young child has a temperature of 101° F. Which action should the nurse take?
- A. Keep child warm with blankets.
- B. Apply a hypothermia blanket.
- C. Record temperature on nurses’ notes.
- D. Report findings to physician.
Correct Answer: D
Rationale: In the first 24 to 48 hours after surgery, the body temperature may increase to 37.7° C (100° F) as part of the inflammatory response to tissue trauma. If the temperature is higher or continues after this period, it is most likely a sign of an infection and immediate investigation is indicated. Blankets should be removed from the child to keep the temperature from increasing. Hypothermia blanket is not indicated for this level of temperature. The temperature should be recorded, but the physician must be notified for evaluation. Suctioning should be done only as indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at one time. Symptoms of respiratory distress are avoided by using appropriate technique.