Nokea
The nurse understands that a patient with BP readings 164/102 and 176/100 on two separate occasions would be classified in which hypertension category?
- A. Prehypertension
- B. Stage 2
- C. Stage 1
- D. Posthypertension
Correct Answer: B
Rationale: According to the guidelines by the American Heart Association (AHA), the patient's blood pressure readings of 164/102 and 176/100 on two separate occasions fall in the Stage 2 hypertension category. Stage 2 hypertension is defined as a systolic blood pressure of 140 mm Hg or higher, or a diastolic blood pressure of 90 mm Hg or higher. The readings provided are significantly above these thresholds, indicating severe hypertension that requires prompt medical attention and management to reduce the risk of complications such as heart disease, stroke, and kidney damage. It is important for healthcare providers to closely monitor and intervene in cases of Stage 2 hypertension to prevent further health complications.
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A nurse is planning a teaching session for parents of a newborn who plan to bottle-feed. Which should the nurse include in the teaching session? (Select all that apply.)
- A. Limiting the feeding to 15 minutes
- B. Propping the bottle for night feedings is acceptable
- C. Proper technique for cleansing the bottles and nipples
- D. Feeding infant on alternate sides of the lap
Correct Answer: C
Rationale: Proper technique for cleansing the bottles and nipples - It is essential to educate parents on the proper technique for cleaning bottles and nipples to prevent bacteria growth and ensure the newborn's milk is not contaminated.
Which type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy?
- A. Neurogenic
- B. Cardiogenic
- C. Hypovolemic
- D. Anaphylactic
Correct Answer: D
Rationale: Anaphylactic shock is characterized by a severe, systemic hypersensitivity reaction that can occur in response to allergens such as certain drugs or latex. During anaphylactic shock, the body releases large amounts of histamine and other inflammatory substances, leading to widespread vasodilation (dilation of blood vessels) and increased capillary permeability. This results in a rapid drop in blood pressure, decreased perfusion to vital organs, and potential life-threatening symptoms such as difficulty breathing and cardiovascular collapse. Immediate treatment with epinephrine and supportive measures such as intravenous fluids is crucial in managing anaphylactic shock.
A first-time mother brings in her 5-day-old baby for a well-child visit. The baby weighs 7 lb 5 oz, down from 7 lb 10 oz at discharge. The nurse's best response is:
- A. I will notify the doctor about this weight loss.
- B. Newborns can lose up to 10% of their birth weight and regain it by 2 weeks of age.
- C. I can tell you are a first-time mother; don't worry.
- D. Maybe the baby isn't getting enough milk. How often are you feeding?
Correct Answer: B
Rationale: A small weight loss is normal in the first week of life; infants typically regain their birth weight by 2 weeks.
Clients will go through operations and who have undergone surgery need the proper observation, treatment, and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria is preparing Mr. Sy for surgery. Which of the following statements by the client would indicate he is well-informed about his imminent surgery?
- A. " Right after the operation, I will wear the pneumatic compression device while sitting on the chair."
- B. "I will not eat anything after 12 pm the night befire my operation, but I sure can drink."
- C. "The skin preparation site is longer and wider than the actual incision site."
- D. "I will need to sign the consent from after I get to the operating table."
Correct Answer: B
Rationale: Option B, "I will not eat anything after 12 pm the night before my operation, but I sure can drink," indicates that the client understands and is knowledgeable about the pre-operative fasting guidelines. It is crucial for patients to have an empty stomach before surgery to prevent complications related to anesthesia, such as aspiration pneumonia. This statement shows that Mr. Sy is well-informed and compliant with this important pre-operative instruction. Options A, C, and D do not directly demonstrate specific knowledge regarding the surgery preparations.
The most common neonatal sepsis and meningitis infections seen within 24 hours after birth are caused by which organism?
- A. Candida albicans
- B. Chlamydia trachomatis
- C. Escherichia coli
- D. Group B beta-hemolytic streptococci
Correct Answer: C
Rationale: Escherichia coli is the most common cause of early-onset neonatal sepsis and meningitis within 24 hours after birth. E. coli can be transmitted from the mother to the infant during delivery, particularly if there is prolonged rupture of membranes or maternal infection. Infections caused by E. coli in newborns can be severe and life-threatening. It is important to identify and promptly treat infections caused by E. coli in neonates to prevent complications and improve outcomes.