Nokea
The thymus gland role with the immune system is which of the following?
- A. Maturates B cells
- B. Maturates platelets
- C. Maturates red blood cells
- D. Maturates T cells
Correct Answer: D
Rationale: The correct answer is D: Maturates T cells. The thymus gland is crucial for the maturation of T cells, a type of white blood cell that plays a central role in the adaptive immune response. T cells mature in the thymus through a process of selection and education, where they learn to distinguish self from non-self antigens. This process is essential for the development of a functional immune system. Choices A, B, and C are incorrect because the thymus gland does not play a role in the maturation of B cells, platelets, or red blood cells, respectively.
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After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions?
- A. To form a language that can be encoded only by nurses
- B. To distinguish the nurse’s role from the physician’s role
- C. To develop clinical judgment based on other’s intuition
- D. To help nurses focus on the scope of medical practice
Correct Answer: D
Rationale: The correct answer is D because developing a formal nursing diagnosis helps nurses focus on their scope of practice, which includes identifying and addressing the patient's nursing care needs. By formulating a clear nursing diagnosis, nurses can prioritize interventions that are within their domain of expertise. This ensures efficient and effective patient care delivery.
A: Incorrect. Developing a nursing diagnosis is not about creating a language exclusive to nurses; it is about identifying patient care needs.
B: Incorrect. While nursing diagnoses do delineate the nurse's role, the primary purpose is not to distinguish it from the physician's role.
C: Incorrect. Nursing diagnoses are based on evidence and critical thinking, not solely on intuition or others' judgments.
The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
- A. Serum potassium level of 4.9mEq/L
- B. Temperature of 99.2F (37.3C)
- C. Serum sodium level of 135mEq/L
- D. Urine output of 20mL/hour
Correct Answer: D
Rationale: The correct answer is D: Urine output of 20mL/hour. This is a critical finding after kidney transplant surgery as it indicates potential kidney dysfunction or acute kidney injury. Decreased urine output can lead to fluid and electrolyte imbalances, which can be life-threatening. Immediate physician notification is crucial for prompt intervention. Choices A, B, and C are within normal ranges and do not indicate immediate danger. Serum potassium level of 4.9mEq/L is slightly elevated but not critical. Temperature of 99.2F (37.3C) is within normal limits for postoperative care. Serum sodium level of 135mEq/L is also normal and does not warrant immediate physician notification.
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
- A. Complete the questions in chronological order.
- B. Focus on the patient’s presenting situation.
- C. Make accurate interpretations of the data.
- D. Conduct an observational overview.
Correct Answer: B
Rationale: The correct answer is B: Focus on the patient’s presenting situation. In the problem-oriented approach, the nurse prioritizes the patient's immediate concerns to address them effectively. By focusing on the presenting situation first, the nurse can gather relevant data and identify key issues. This step ensures that the nurse addresses the most pressing problems promptly.
A: Completing questions in chronological order may not be necessary and could delay addressing the immediate concern.
C: Making accurate interpretations of data should come after gathering relevant information about the presenting situation.
D: Conducting an observational overview is important but should come after focusing on the patient's presenting situation to gather specific data.
Which of the ff vessels is often used for grafting?
- A. The basic and cephalic veins in the arm
- B. The internal mammary and internal thoracic arteries in the chest
- C. The saphenous vein in the leg
- D. The radial artery in the arm
Correct Answer: B
Rationale: The correct answer is B because the internal mammary and internal thoracic arteries in the chest are commonly used for grafting due to their size, durability, and long-term patency. These arteries have a better track record for successful grafting procedures compared to the other options. The basic and cephalic veins in the arm (Option A) are typically used for venous procedures, not arterial grafting. The saphenous vein in the leg (Option C) is also commonly used for grafting, but the internal mammary and internal thoracic arteries are preferred for their better outcomes. The radial artery in the arm (Option D) is less commonly used for grafting compared to the internal mammary and internal thoracic arteries.
Which of the following is classified as subjective data in a nursing assessment?
- A. Heart rate of 90 beats per minute
- B. Client states, 'I feel nauseated.'
- C. Blood pressure of 130/80 mmHg
- D. Skin appears flushed
Correct Answer: B
Rationale: The correct answer is B because subjective data in a nursing assessment refers to information provided by the patient, such as feelings, perceptions, and symptoms. In this case, the client stating 'I feel nauseated' represents subjective data. This type of information cannot be measured or observed directly.
A, C, and D are incorrect:
A: Heart rate of 90 beats per minute is an objective measurement that can be directly observed.
C: Blood pressure of 130/80 mmHg is also an objective measurement that can be directly observed.
D: Skin appears flushed is an objective observation that can be directly seen.