The reason that the hematocrit is so high is
- A. chronic hypoxia
- B. it was taken in a low cardiac output state
- C. it was a peripheral finger stick
- D. embolic stroke
Correct Answer: A
Rationale: Chronic hypoxia leads to secondary polycythemia as a compensatory mechanism.
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The nurse is caring for a child with a diagnosis of Kawasaki disease. The child’s parent asks the nurse, “How does Kawasaki disease affect my child’s heart and blood vessels?†On what understanding is the nurse’s response based?
- A. Inflammation weakens blood vessels, leading to aneurysm.
- B. Increased lipid levels lead to the development of atherosclerosis.
- C. Untreated disease causes mitral valve stenosis.
- D. Altered blood flow increases cardiac workload with resulting heart failure.
Correct Answer: A
Rationale: Inflammation of vessels weakens the walls of the vessels and often results in aneurysm.
The enzyme producing carbon monoxide within the human body is
- A. Aminolevulinic acid synthase
- B. Heme oxygenase
- C. Cyclo-oxygense
- D. Nitric oxide synthase
Correct Answer: B
Rationale: Heme oxygenase is responsible for the production of carbon monoxide during the breakdown of heme.
Which assessment indicates that the parent of a 7-year-old is following the prescribed treatment for congestive heart failure (CHF)?
- A. HR of 56 beats per minute
- B. Elevated red blood cell count
- C. 50th percentile height and weight for age
- D. Urine output of 0.5 cc/kg/hr
Correct Answer: C
Rationale: Normal growth (50th percentile) indicates good nutrition and overall health, suggesting that CHF is well controlled.
A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse?
- A. Serum sodium of 185 mEq/L
- B. Urine output of 3000 mL per hour.
- C. Blood pressure of 90/60 mmHg.
- D. Potassium level of 4.5 mEq/L.
Correct Answer: A
Rationale: A serum sodium level of 185 mEq/L indicates severe hypernatremia, which is life-threatening and requires immediate intervention.
A diagnosis of primary pulmonary hypertension of the newborn can be made if:
- A. Oxygen saturation in the hand is 80% and in the foot 67%
- B. A tachypnoeic baby has a saturation of 60%
- C. A baby with history of being covered in thick meconium at birth has PaO2 of 4kPa
- D. A septic baby is hypoxic in 100% oxygen
Correct Answer: A
Rationale: A significant difference in oxygen saturation between the upper and lower extremities (e.g., hand 80%, foot 67%) is indicative of persistent pulmonary hypertension of the newborn (PPHN).