Nokea
The nurse is preparing to administer a unit of blood to a client's who's anemic. After its removal from the refrigerator, the blood should be administered within:
- A. 1 hour
- B. 4 hours
- C. 2 hours
- D. 6 hours
Correct Answer: B
Rationale: After blood is removed from the refrigerator, it should be administered within 4 hours. Blood should be stored in a controlled temperature environment to prevent bacterial growth and to maintain its effectiveness. In order to minimize the risk of bacterial contamination, it is important for the nurse to adhere to the recommended time frame for administering blood products. Administering the blood within 4 hours helps ensure its safety and effectiveness for the client.
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Which finding would you expect in a 4-week-old with biliary atresia?
- A. Abdominal distention, enlarged liver and spleen, clay-colored stools, and tea-colored urine.
- B. Abdominal distention with bruises and hematuria.
- C. Yellow sclera/skin, oily skin, and prolonged bleeding times.
- D. No manifestations until advanced disease.
Correct Answer: A
Rationale: Biliary atresia typically presents with hepatosplenomegaly, pale stools, and dark urine due to impaired bile excretion.
Hemangiomas are the most common benign tumors of infancy, occurring more in full-term infants. Of the following, the most common risk factor of development of hemangioma is
- A. male infant
- B. female infant
- C. infant of diabetic mother
- D. infant delivered by cesarean section
Correct Answer: B
Rationale: Female infants are at higher risk for developing hemangiomas.
An adult is on long term aspirin therapy and is experiencing tinnitus. What is the best interpretation of this occurrence?
- A. The aspirin is working correctly
- B. The client has an upper GI bleed
- C. The client has a metal taste in their mouth
- D. The client is experiencing a mild overdosage
Correct Answer: D
Rationale: Tinnitus (ringing in the ears) is a potential side effect of aspirin overdose. Aspirin can cause toxicity with symptoms like ringing in the ears, dizziness, confusion, and nausea. It is important for the adult to seek medical attention if they are experiencing tinnitus while on long-term aspirin therapy to address the possible overdose situation.
A preterm newborn requires oxygen and mechanical ventilation. Which complications should the nurse assess for?
- A. Bronchopulmonary dysplasia, pneumothorax
- B. Anemia, necrotizing enterocolitis
- C. Cerebral palsy, persistent patent ductus
- D. Congestive heart failure, cerebral edema
Correct Answer: A
Rationale: Preterm newborns who require oxygen and mechanical ventilation are at risk for developing bronchopulmonary dysplasia (BPD) and pneumothorax. BPD is a chronic lung disease that can occur in premature infants who have been on mechanical ventilation and supplemental oxygen. Pneumothorax is another common complication in preterm newborns due to the fragility of their lungs. Therefore, the nurse should closely monitor for signs and symptoms of these complications in a preterm newborn requiring oxygen and mechanical ventilation.
Undescended testis is a risk factor for the development of which of the following tumors?
- A. rhabdomyosarcoma
- B. leukemia
- C. yolk sac tumor
- D. lymphoma
Correct Answer: C
Rationale: Undescended testis is a well-documented risk factor for yolk sac tumors and other testicular cancers.