Nokea
The nurse is caring for a patient receiving warfarin therapy. Which of the following findings is essential to report to the physician?
- A. Bleeding time 3 (normal = 2-5 sec) c.PTT 29 (normal = 30-45 sec)
- B. INR 4 (normal = 2-3 sec)
- C. PT 20 (normal = 9-12 sec)
Correct Answer: B
Rationale: An INR of 4 is higher than the normal therapeutic range for patients receiving warfarin therapy, which is typically between 2-3. An INR value above the therapeutic range indicates that the patient is at an increased risk of bleeding complications. Therefore, it is essential to report this finding to the physician for further evaluation and possible adjustment of the warfarin dosage to prevent excessive bleeding. The other values provided (A and C) are within or close to the normal ranges, so they would not warrant immediate concern compared to the elevated INR level.
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Mr Santos is scheduled for CT SCAN for the next day, noon time. Which of the following is the correct preparation as instructed by the nurse?
- A. Shampoo hair thoroughly to remove oil and dirt
- B. No special preparation is needed. Instruct the patient to keep his head still and stead
- C. Give a cleansing enema and give fluids until 8 AM
- D. Shave scalp and securely attach electrodes to it
Correct Answer: A
Rationale: The correct preparation for a CT scan, in this case, does not involve any special instructions such as shampooing hair, giving an enema, or shaving the scalp. The patient is simply instructed to keep their head still and steady during the scan. CT scans do not require any specific preparation unless explicitly stated by the healthcare provider conducting the test. It is important to follow the nurse's or healthcare provider's instructions carefully to ensure the best results from the CT scan.
Nurse Beverly is giving preoperative instructions to Ian who is scheduled for an Ileostomy. Which of the following would be included?
- A. "Your urine will be collected in a pouch following surgery."
- B. "You will have a nasogastric tube after surgery."
- C. "Your bowel will be visualized with a laparoscope during surgery."
- D. "You can drink liquids within 24 hours after surgery."
Correct Answer: A
Rationale: An ileostomy is a surgical procedure that involves creating a stoma from the ileum (part of the small intestine) to the abdominal wall, allowing waste to bypass the colon and exit the body through the stoma into a pouch worn on the outside of the body. Therefore, it is important for Nurse Beverly to inform Ian that his stool output will be collected in a pouch following the surgery. Option A is the correct choice as it directly relates to the postoperative care and management specific to an ileostomy procedure.
A nurse is assessing a child with kwashiorkor disease. Which assessment findings should the nurse expect?
- A. Thin wasted extremities with a prominent abdomen
- B. Constipation
- C. Elevated hemoglobin
- D. High levels of protein
Correct Answer: A
Rationale: Kwashiorkor is a form of severe acute malnutrition characterized by a deficiency in protein intake, leading to a protein-energy malnutrition. One of the hallmark signs of kwashiorkor is an enlarged, protruding abdomen due to fluid retention in the tissues (edema), giving the appearance of a swollen belly. Additionally, individuals with kwashiorkor often have thin, wasted extremities while their abdomen appears disproportionately distended. This is known as the "big belly, skinny limbs" presentation, which arises due to the imbalance of protein and energy intake. Therefore, the nurse assessing a child with kwashiorkor should expect to find thin wasted extremities with a prominent abdomen.
The bronchospasm and dyspnea are clinical manifestation of organophosphorus poisoning are caused by :
- A. muscarinic action
- B. nicotinic action
- C. CNS action
- D. all the above
Correct Answer: A
Rationale: The bronchospasm and dyspnea seen in organophosphorus poisoning are primarily caused by the muscarinic action of the toxic substance. Organophosphates inhibit acetylcholinesterase, leading to an excess of acetylcholine at the neuromuscular junctions. This results in overstimulation of muscarinic receptors, causing symptoms such as bronchoconstriction, increased secretions, and respiratory distress. Nicotinic actions primarily lead to muscle weakness and paralysis, while CNS actions can cause seizures and altered mental status. So, in the case of bronchospasm and dyspnea, the muscarinic action is the main contributing factor.
Bell's palsy is a ___ cranial nerve disorder characterized by weakness or paralysis of the facial muscles.
- A. 3rd
- B. 7th
- C. 5th
- D. 8th
Correct Answer: B
Rationale: Bell's palsy is a cranial nerve disorder characterized by weakness or paralysis of the facial muscles due to inflammation, compression, or damage to the seventh cranial nerve - the facial nerve. The facial nerve controls the muscles responsible for facial expressions and functions like smiling, closing the eyes, and raising the eyebrows. Symptoms of Bell's palsy can include drooping of one side of the face, difficulty in closing one eye, drooling, impaired taste, and difficulty in smiling.