Nokea
The nurse is careful to place the incubator away from cold windows or air-conditioning units. This is to conserve the newborn's body heat by preventing heat loss through:
- A. radiation.
- B. conduction.
- C. convection.
- D. evaporation.
Correct Answer: A
Rationale: Placing the incubator away from cold windows or air-conditioning units helps prevent heat loss through radiation. Radiation is the transfer of heat in the form of electromagnetic waves, such as infrared radiation, from a warmer object to a cooler one without direct contact. In this case, the newborn's body heat could be lost to the colder objects (windows or air-conditioning units) through radiation if they were in close proximity. By placing the incubator away from these cold surfaces, the nurse can minimize the heat loss through radiation and help conserve the newborn's body heat.
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The Foley Family is caring for their youngest child, Justin, who is suffering from tetralogy of Fallot. Which of the following are defects associated with this congenital heart condition?
- A. Aorta exits from the right ventricle, pulmonary artery exits from the left ventricle, and two noncommunicating circulations
- B. Ventricular septal defect, overriding aorta, pulmonic stenosis (PS), and right ventricular hypertrophy
- C. Coarctation of aorta, aortic valve stenosis, mitral valve stenosis, and patent ductus arteriosus
- D. Tricuspid valve atresia, atrial septal defect, ventricular septal defect, and hypoplastic right ventricle
Correct Answer: B
Rationale: Tetralogy of Fallot is a congenital heart condition characterized by four specific defects:
During the nursing interview Toni minimizes her visual problems talks about remaining in school to attempt advanced degrees, requests information about full-time jobs in nursing and mentions her desire to have several more children. The nurse recognizes her emotional responses as being:
- A. An example of inappropriate euphoria characteristic of the disease process
- B. A reflection of coping mechanisms used to deal with the exacerbation of her illness
- C. Indicative of the remission phase of her chronic illness
- D. Realistic for her current level of physical functioning
Correct Answer: A
Rationale: Toni's response of minimizing her visual problems, talking about pursuing advanced degrees, asking about full-time job opportunities in nursing, and mentioning her desire to have more children despite her current health situation may suggest inappropriate euphoria characteristic of the disease process. Inappropriate euphoria can be a sign of an altered mental state that is not in line with the reality of the situation. It is important for healthcare providers to recognize such emotional responses as they may indicate underlying mental health issues or the need for further assessment and support.
A client is undergoing test for multiple myeloma. Diagnostic study findings in multiple Myeloma includes:
- A. A decreased serum creatinine level.
- B. Bence jones protein in the urine.
- C. Hypocalcemia.
- D. A low serum protein level.
Correct Answer: B
Rationale: Diagnostic study findings in multiple myeloma often include the presence of Bence Jones protein in the urine. Bence Jones protein is a type of abnormal protein (immunoglobulin light chain) produced by the abnormal plasma cells in multiple myeloma. Its presence in the urine can be detected through urine protein electrophoresis and is a characteristic feature of the disease. Other common findings in multiple myeloma include hypercalcemia, elevated serum creatinine level, and high serum protein level due to the excess production of monoclonal immunoglobulins.
A client with colon cancer requires a permanent colostomy because of the tumor location. After surgery, the client must learn how to irrigate the colostomy. When irrigating, how far into the stoma should the client insert the lubricated catheter?
- A. 0.25" to 0.5"
- B. 2" to 4"
- C. 1" to 1.5"
- D. 5" to 7"
Correct Answer: C
Rationale: When irrigating a colostomy, the client should insert the lubricated catheter approximately 1 to 1.5 inches (2.5 to 4 cm) into the stoma. This depth ensures that the catheter reaches the optimal level within the colon to effectively irrigate and cleanse the colon contents. Inserting the catheter too shallow may not reach the colon, while inserting it too deep can cause discomfort or injury to the lining of the colon. It is important for the client to be educated on the correct technique and depth for colostomy irrigation to maintain bowel regularity and health.
Which of the ff precautions must a nurse take while caring for clients with HIV/AIDS to reduce occupational risks?
- A. Transport specimens of body fluid in leakproof containers
- B. Seek prescription for a fusion inhibitor to reduce risk of infection
- C. Avoid administering IV drugs
- D. Avoid cleaning the clients room, esp cleaning urine, stool, or vomit
Correct Answer: A
Rationale: When caring for clients with HIV/AIDS to reduce occupational risks, a nurse must take precautions to minimize the risk of exposure to body fluids that may contain the HIV virus. Transporting specimens of body fluid in leakproof containers helps prevent accidental spills or leakages that could lead to exposure. Proper handling and containment of body fluids are essential to reducing the risk of transmission of HIV to healthcare workers. This precaution is in line with standard infection control practices to ensure the safety of healthcare providers and minimize the risk of occupational exposure to bloodborne pathogens like HIV.