Nokea
The nurse is planning care for a low birth weight newborn. Which is an appropriate nursing intervention to promote adequate oxygenation?
- A. Place in Trendelenburg position periodically.
- B. Suction at least every 2 to 3 hours.
- C. Maintain neutral thermal environment.
- D. Hyperextend neck with nose pointing to ceiling.
Correct Answer: C
Rationale: Maintaining a neutral thermal environment is an appropriate nursing intervention to promote adequate oxygenation in a low birth weight newborn. Newborns, especially those with low birth weight, have limited capacity to regulate their body temperature. Keeping the baby warm helps prevent cold stress, which can lead to increased metabolic demands and oxygen consumption. By maintaining a neutral thermal environment, the newborn's energy can be directed towards growth and development, rather than compensating for temperature fluctuations. This intervention helps optimize oxygenation and overall well-being of the low birth weight newborn. The other options (A, B, D) do not directly address the need for adequate oxygenation in a low birth weight newborn.
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A patient is admitted who has had severe vomiting for 24 hours. She states that she is exhausted and weak. The results of an admitting ECG show flat T waves and ST segment depression. Choose the most likely potassium (K ) value for this patient.
- A. 4.0mEq/L
- B. 2.0mEq/L
- C. 8.0mEq/L
- D. 2.6mEq/L
Correct Answer: B
Rationale: The patient is displaying signs of hypokalemia (low potassium levels) due to severe vomiting. Symptoms of hypokalemia can include weakness, fatigue, and ECG changes such as flat T waves and ST segment depression. The potassium level that is most likely associated with these symptoms is 2.0mEq/L. Severe vomiting can lead to significant loss of potassium from the body, causing these abnormalities. It is important to address and correct the potassium imbalance to prevent further complications.
A client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis site for cancer cells?
- A. Liver
- B. Reproductive tract
- C. Colon
- D. White blood cells (WBCs)
Correct Answer: A
Rationale: The liver is one of the most common sites for metastasis of cancer cells. This is because the liver receives a high volume of blood flow, making it a common site for cancer cells to spread through the bloodstream. Additionally, the liver's function in filtering toxins and foreign substances from the blood makes it a favorable environment for cancer cells to establish secondary tumors. Monitoring the liver for metastasis is crucial in cancer diagnosis and management.
Antihistamines are used cautiously in older men with prostatic hypertrophy for which of the ff reasons?
- A. Because the clients may experience increased drowsiness
- B. Because these clients may experience difficulty voiding
- C. Because these clients face a greater risk of cardiac arrest
- D. Because these clients have a lower autoimmune response CARING FOR CLIENTS WITH AIDS
Correct Answer: B
Rationale: Antihistamines are used cautiously in older men with prostatic hypertrophy (enlarged prostate) because these clients may experience difficulty voiding. Antihistamines can cause urinary retention by causing decreased bladder contractility and relaxation of the bladder neck muscles. In individuals with prostatic hypertrophy, there is already an increased risk of urinary retention due to obstruction caused by the enlarged prostate. Therefore, the use of antihistamines can exacerbate this condition, leading to further difficulty in urination. It is important to monitor these individuals closely and consider alternative medications that do not pose a risk of worsening urinary symptoms.
Which is an accurate description of a Kasai procedure?
- A. A palliative procedure in which the bile duct is attached to a loop of bowel to assist with bile drainage.
- B. A curative procedure that connects the bile duct to the bowel.
- C. A curative procedure where the bile duct is banded.
- D. A palliative procedure where the bile duct is banded.
Correct Answer: A
Rationale: The Kasai procedure is a palliative surgery for biliary atresia that helps restore bile flow and delays the need for liver transplantation.
A client with allergic rhinitis is prescribed loratadine (Claritin). On a follow-up visit, the client tells the nurse, "I take one 10-mg of Claritin with a glass of water two times daily". The nurse concludes that the client requires additional teaching about this medication because:
- A. Loratadine isn't available in 10mg tablets
- B. Loratadine should be taken on an empty stomach
- C. Loratadine should be taken once daily for allergenic rhinitis
- D. Claritin isn't the trade name for loratadine
Correct Answer: C
Rationale: Loratadine (Claritin) is typically taken once daily for allergic rhinitis. Taking it two times daily as stated by the client is unnecessary and indicates a lack of understanding about the appropriate dosing schedule for this medication. Claritin is indeed the trade name for loratadine, and it is available in 10mg tablets, but the issue here is the incorrect dosing frequency.