Nokea
The patient experienced a blood transfusion reaction. How should the nurse explain to the patient the cause of the hemolytic jaundice that occurred?
- A. Results from hepatocellular disease
- B. Due to a malaria parasite breaking apart red blood cells (RBCs)
- C. Results from decreased flow of bile through the liver or biliary system
- D. Due to increased breakdown of RBCs that caused elevated serum unconjugated bilirubin
Correct Answer: D
Rationale: The correct answer is D. Hemolytic jaundice in a blood transfusion reaction is due to increased breakdown of red blood cells (RBCs) causing elevated serum unconjugated bilirubin. This occurs when the patient's immune system reacts to the transfused blood, leading to destruction of RBCs. The breakdown of these cells releases hemoglobin, which is metabolized into bilirubin. This unconjugated bilirubin then accumulates in the blood, causing jaundice.
Choice A is incorrect because hepatocellular disease does not directly cause hemolytic jaundice. Choice B is incorrect as malaria parasite breaking apart RBCs leads to hemolysis, not a blood transfusion reaction. Choice C is incorrect as decreased bile flow through the liver or biliary system typically causes obstructive jaundice, not hemolytic jaundice.
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The optimum pH for trypsin and chymotrypsin is about
- A. 1-3.
- B. 5-7.
- C. 7-9.
- D. 10-12.
Correct Answer: C
Rationale: The correct answer is C (7-9) because trypsin and chymotrypsin are proteolytic enzymes that function optimally in slightly basic environments. At pH 7-9, these enzymes maintain their structural integrity and catalytic activity. Choices A, B, and D are incorrect because trypsin and chymotrypsin are not acidic enzymes, so pH ranges 1-3 and 10-12 would denature and inactivate them, while pH 5-7 is still on the acidic side, not optimal for these enzymes.
Which of these structures is found in the small intestine?
- A. Villi
- B. Hepatic portal vein
- C. Goblet cells
- D. Mesenteries
Correct Answer: A
Rationale: The correct answer is A: Villi. Villi are finger-like projections lining the small intestine that increase surface area for nutrient absorption. This structure is crucial for efficient digestion and absorption of nutrients. The other choices are incorrect because:
B: Hepatic portal vein - This structure is not found in the small intestine but connects the intestines to the liver.
C: Goblet cells - While present in the small intestine, they are not a defining structure of the small intestine.
D: Mesenteries - These are connective tissues that support and hold organs in place, not a structure specific to the small intestine.
While a female client is being prepared for discharge, the nasogastric (NG) feeding tube becomes clogged. To remedy this problem and teach the client's family how to deal with it at home, what should the nurse do?
- A. Irrigate the tube with warm water.
- B. Advance the tube into the intestine.
- C. Apply intermittent suction to the tube.
- D. Withdraw the obstruction with a 30-ml syringe.
Correct Answer: A
Rationale: The correct answer is A: Irrigate the tube with warm water. This is the correct action because irrigating the NG tube with warm water can help dislodge the clog and clear the obstruction. Here is a step-by-step rationale:
1. Gather necessary supplies: warm water, syringe, and towel.
2. Disconnect the tube from the feeding pump.
3. Draw up warm water into the syringe.
4. Gently insert the syringe into the tube and slowly push the warm water to flush out the clog.
5. Repeat the process as needed until the tube is clear.
Other choices are incorrect:
B: Advancing the tube into the intestine can be dangerous and should not be done without proper medical supervision.
C: Applying intermittent suction may not effectively clear the clog and could potentially worsen the situation.
D: Using a 30-ml syringe to withdraw the obstruction may not be as effective as irrigating with warm water.
The nurse is educating a group of older adults on ways to prevent falls. Which statement made by an older adult indicates the need for further teaching?
- A. "I will make sure that I wear my glasses when I walk outside."
- B. "I should make sure my home is free of clutter to prevent tripping."
- C. "I'll make sure I get up slowly from a sitting position to prevent dizziness."
- D. "I won't need to wear shoes in the house since I am only walking a short distance."
Correct Answer: D
Rationale: The correct answer is D. Walking barefoot increases the risk of slipping and falling, especially for older adults with balance issues. Wearing shoes indoors provides stability and reduces the risk of falls. Choices A, B, and C all demonstrate good fall prevention strategies by addressing vision, home safety, and orthostatic hypotension respectively.
A hiatal hernia is a weakness in the _____ muscle, which allows a portion of the digestive tract to enter the thoracic cavity.
- A. diaphragm
- B. stomach
- C. intestinal
- D. thoracic wall
Correct Answer: A
Rationale: The correct answer is A: diaphragm. The diaphragm is a dome-shaped muscle that separates the thoracic and abdominal cavities. A hiatal hernia occurs when the stomach pushes through the opening in the diaphragm known as the esophageal hiatus, allowing a portion of the stomach to enter the thoracic cavity. The other choices, B: stomach, C: intestinal, and D: thoracic wall, are incorrect because a hiatal hernia specifically involves a weakness in the diaphragm muscle, not in these other structures. The stomach is the organ affected by the hernia, but the primary issue lies in the diaphragm's weakness. The intestinal and thoracic wall choices are not directly related to the development of a hiatal hernia.