Nokea
The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client?
- A. Grafting increases the risk for bacterial infections
- B. The xenograft is taken from nonhuman sources
- C. Grafts are later removed by a debriding procedure
- D. As the burn heals, the graft permanently attaches
Correct Answer: B
Rationale: This information is crucial for the client to understand the nature of the graft and its source.
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During a well-child checkup for an infant with tetralogy of Fallot (TOF), the child develops severe respiratory distress and becomes cyanotic. The nurse's first action should be to:
- A. Lay the child flat to promote hemostasis
- B. Lay the child flat with legs elevated to increase blood flow to the heart
- C. Sit the child on the parent's lap, with legs dangling, to promote venous pooling
- D. Hold the child in knee-chest position to decrease venous blood return
Correct Answer: D
Rationale: The knee-chest position increases systemic vascular resistance (SVR), which increases blood flow to the pulmonary artery.
The following antibiotics interfere with bacterial translation:
- A. Penicillin
- B. Ceftriaxone
- C. Azithromycin
- D. Ciprofloxacin
Correct Answer: C
Rationale: Azithromycin, a macrolide antibiotic, inhibits bacterial protein synthesis by binding to the 50S ribosomal subunit, thereby interfering with translation.
Features of congenital rubella syndrome include:
- A. Intrauterine growth retardation
- B. Hepatomegaly
- C. Thrombocytopenia
- D. Polydactyly
Correct Answer: A
Rationale: Intrauterine growth retardation is a classic feature of congenital rubella syndrome due to the teratogenic effects of the virus.
A father asks why his child with tetralogy of Fallot seems to favor a squatting position. What is the nurse’s best response?
- A. Squatting increases the return of venous blood back to the heart.
- B. Squatting decreases arterial blood flow away from the heart.
- C. Squatting is a common resting position when a child is tachycardic.
- D. Squatting increases the workload of the heart.
Correct Answer: A
Rationale: The squatting position allows the child to breathe more easily because systemic venous return is increased.
A client who weighs 175 pounds is receiving IV bolus dose of heparin 80 units/kg. The heparin is available in a 2 ml vial, labeled 10,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)
- A. 0.6
- C. 6
- D. 1
Correct Answer: A
Rationale: The calculation is based on the client's weight and the prescribed dosage of heparin.