Nokea
The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess urine output?
- A. Inserting a foley catheter.
- B. Weighing the diapers.
- C. Comparing intake with output.
- D. Measuring the amount of water added to the formula.
Correct Answer: B
Rationale: Weighing diapers is a non-invasive and accurate method to assess urine output in infants, which is crucial for monitoring the effectiveness of diuretic therapy.
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What is the most likely congenital heart lesion in a newborn with Trisomy 21?
- A. AVSD
- B. Tetralogy of Fallot
- C. Ventricular septal defect
- D. Pulmonary stenosis
Correct Answer: A
Rationale: Atrioventricular septal defect (AVSD) is highly associated with Trisomy 21 and is the most likely congenital heart lesion in these infants.
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.
Diagnosis of nocturnal enuresis can be made in:
- A. A 3-year-old boy with recurrent bedwetting
- B. A 4-year-old who has started bedwetting after attaining complete toilet control at 3½ years of age
- C. A 5-year-old girl who is recently staining her underclothes at school
- D. A 6-year-old recovering from a recent UTI
Correct Answer: B
Rationale: A 4-year-old who has started bedwetting after attaining complete toilet control at 3½ years of age: Nocturnal enuresis is diagnosed if bedwetting persists beyond the age of 5, especially if it starts after toilet training.
A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet; swelling, redness, and restricted joint motion; and reports feeling fatigued. Which nursing diagnosis has the highest priority for this client?
- A. Pain related to joint inflammation
- B. Impaired physical mobility.
- C. Risk for infection.
- D. Disturbed sleep pattern.
Correct Answer: A
Rationale: Pain is the most immediate and distressing symptom for the client and should be addressed first to improve comfort and quality of life.
All of the following are useful indicators regarding the severity of Tetralogy of Fallot
- A. Systemic arterial oxygen saturation
- B. Intensity of outflow murmur
- C. Functional class
- D. Right ventricular outflow gradient by echocardiography
Correct Answer: B
Rationale: The intensity of the outflow murmur is not a reliable indicator of the severity of Tetralogy of Fallot.