Nokea
The nurse is preparing a parent of a newborn for home phototherapy. Which statement made by the parent would indicate a need for further teaching?
- A. "I should change the baby's position many times during the day."
- B. "I can dress the baby in lightweight clothing while under phototherapy."
- C. "I should be sure that the baby's eyelids are closed before applying patches."
- D. "I can take the patches off the baby during feedings and other caregiving activities."
Correct Answer: D
Rationale: The correct statement should be that the patches need to remain on the baby's eyes at all times during phototherapy. Removing the eye patches can potentially allow harmful light exposure to the eyes, which can lead to complications such as eye damage. It is essential for the parent to understand the importance of keeping the eye patches on to protect the baby's eyes during phototherapy. Therefore, further teaching is needed to emphasize the importance of leaving the eye patches on at all times, even during feedings and caregiving activities.
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You are discussing with medical students the role of chemotherapy in malignant germ cell tumors (GCTs); you state that GCTs are sensitive to some types of chemotherapy. Of the following, the MOST effective chemotherapeutic agent in GCTs is
- A. vincristine
- B. cyclophosphamide
- C. cisplatin
- D. methotrexate
Correct Answer: C
Rationale: Cisplatin is a cornerstone in the treatment of germ cell tumors.
Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:
- A. Obtain vita! Signs
- B. Assess the pain further
- C. Stop the transfusion
- D. Increase the flow of normal saline SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Correct Answer: C
Rationale: Lumbar pain during a blood transfusion can be a sign of an adverse reaction, such as a transfusion reaction. Any complaints of pain during a transfusion should not be ignored. In this case, the nurse should first stop the transfusion to prevent any further complications. The client should be assessed promptly for other signs of a transfusion reaction, and appropriate actions should be taken as needed to ensure the client's safety and well-being.
The client with myasthenia gravis has become increasingly weaker. The physician prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium (Tensilon) is administered. Which of the following would indicate that the client is in cholinergic crisis?
- A. No change in the condition
- B. An improvement of the weakness
- C. Complaints of muscle spasms
- D. A temporary worsening of the condition
Correct Answer: D
Rationale: Administering edrophonium (Tensilon) to a client with myasthenia gravis helps differentiate between cholinergic crisis and myasthenic crisis. In cholinergic crisis, which is caused by excessive acetylcholine levels due to an overdose of anticholinesterase medications, the client may experience a temporary worsening of symptoms such as muscle weakness, respiratory distress, and other cholinergic effects. This temporary worsening is due to the increase in acetylcholine levels, leading to overstimulation of nicotinic and muscarinic receptors. On the other hand, in myasthenic crisis, which is caused by insufficient acetylcholine at the neuromuscular junction, administering edrophonium would lead to an improvement in muscle weakness. Therefore, if the client experiences a temporary worsening of symptoms after receiving edrophonium, it indicates cholinergic crisis.
A pregnant client requires immediate but temporary protection from chickenpox. Which type of immunization would be required?
- A. Naturally acquired active immunization
- B. Artificially acquired passive
- C. Artificially acquired active immunization immunization
- D. Passive immunization
Correct Answer: D
Rationale: Passive immunization involves the administration of pre-formed antibodies rather than stimulating the individual's immune system to produce its own antibodies (active immunization). In the case of a pregnant client requiring immediate but temporary protection from chickenpox, passive immunization would be the most appropriate choice. This is because passive immunization can provide immediate protection without activating the pregnant individual's immune system, which could pose potential risks during pregnancy. By introducing pre-formed antibodies against chickenpox, the pregnant client can acquire temporary immunity to the virus, safeguarding both her and her developing baby.
A mother requests that her child receive the varicella vaccine at the 9-month checkup. The nurse's best response is:
- A. Vaccinated children will likely develop a mild case of chickenpox.
- B. The varicella vaccine is not usually administered before 1 year of age.
- C. The vaccine will be given after the doctor examines your child.
- D. A booster will be needed at 18 months.
Correct Answer: B
Rationale: The varicella vaccine is typically not given until the child is 12 months or older.