Nokea
The nurse is aware that the shift of body fluids associated with the intravenous administration of albumin occurs by the process of:
- A. Filtration
- B. Osmosis
- C. Diffusion
- D. Active Transport
Correct Answer: B
Rationale: Osmosis is the process by which water moves across a semi-permeable membrane to equalize concentrations on both sides of the membrane. When albumin is administered intravenously, it creates an osmotic pressure in the bloodstream that draws water from the interstitial space into the blood vessels. This shift of body fluids associated with the intravenous administration of albumin occurs through the process of osmosis.
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Which of the following infants is least probable to develop sudden infant death syndrome (SIDS)?
- A. Baby Angela who was premature
- B. A sibling of Baby Angie who died of SIDS
- C. Baby Gabriel with prenatal drug exposure
- D. Baby Gabby who sleeps on his back
Correct Answer: B
Rationale: Sibling of Baby Angie who died of SIDS is the least probable to develop sudden infant death syndrome (SIDS) among the given choices. This is because siblings of infants who have died of SIDS are at a higher risk themselves due to potential genetic or environmental factors. Research suggests that siblings of infants who died of SIDS are at an increased risk compared to the general population, indicating a possible genetic predisposition or shared environmental influences. It is crucial for parents and caregivers of these siblings to take extra precautions and follow safe sleep practices to reduce the risk of SIDS.
Janae has a seizure disorder; which of the following would be the lowest priority when caring for her? Observing and taking down data on all seizures
- A. Assuring safety and protection from injuring
- B. Assessing for signs and symptoms of increased intracranial pressure (ICP)
- C. Educating the family about anticonvulsant therapy
Correct Answer: C
Rationale: When caring for someone with a seizure disorder like Janae, the highest priority is ensuring their immediate safety and protection from injury during a seizure. This includes preventing falls, removing nearby hazards, and providing support during and after the seizure. Assessing for signs and symptoms of increased intracranial pressure is also important as it may indicate a serious complication requiring prompt medical attention. On the other hand, educating the family about anticonvulsant therapy, while important for long-term management, is considered a lower priority compared to the immediate safety and medical assessment needs of Janae during a seizure episode.
Which vein should be used first when initiating IV therapy?
- A. Jugular
- B. Basilic
- C. Brachiocephalic
- D. Axillary
Correct Answer: B
Rationale: When initiating IV therapy, the basilic vein is often used first due to its accessibility and size. The basilic vein is a common choice for venipuncture because it is located on the medial aspect of the arm and tends to be easily palpable. Additionally, the basilic vein is also less prone to complications such as nerve damage compared to other deeper veins like the jugular or brachiocephalic veins. Therefore, utilizing the basilic vein as the initial site for IV therapy is a safe and efficient choice.
Which type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy?
- A. Neurogenic
- B. Cardiogenic
- C. Hypovolemic
- D. Anaphylactic
Correct Answer: D
Rationale: Anaphylactic shock is characterized by a severe, systemic hypersensitivity reaction that can occur in response to allergens such as certain drugs or latex. During anaphylactic shock, the body releases large amounts of histamine and other inflammatory substances, leading to widespread vasodilation (dilation of blood vessels) and increased capillary permeability. This results in a rapid drop in blood pressure, decreased perfusion to vital organs, and potential life-threatening symptoms such as difficulty breathing and cardiovascular collapse. Immediate treatment with epinephrine and supportive measures such as intravenous fluids is crucial in managing anaphylactic shock.
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care?
- A. Administering aspirin if the temperature exceeds 102â—‹1 F (38.8â—‹0 C)
- B. inspecting the skin for petechiae once every shift
- C. providing for frequent rest periods
- D. Placing the client in strict isolation
Correct Answer: C
Rationale: Providing for frequent rest periods is the most appropriate intervention for a client newly diagnosed with radiation-induced thrombocytopenia. Thrombocytopenia is characterized by a decreased number of platelets, which are essential for blood clotting. Clients with thrombocytopenia are at an increased risk for bleeding and bruising. Therefore, it is important to prevent activities that may lead to injury or bleeding. Providing frequent rest periods allows the client to conserve energy and minimize the risk of trauma that could lead to bleeding complications. This intervention helps manage the symptoms associated with thrombocytopenia and promotes the client's safety and well-being.