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To prevent leakage of fluid in the thoracic cavity, how will you position the client after thoracentesis?
- A. Place flat in bed
- B. Turn on the affected side
- C. Turn on the unaffected side
- D. On bed rest SENSORY DISORDERS
Correct Answer: C
Rationale: After thoracentesis, it is important to position the client on the unaffected side to prevent leakage of fluid into the thoracic cavity. Placing the client on the unaffected side helps to promote proper drainage and reduce the risk of complications such as pneumothorax or fluid leakage. This position also allows for adequate lung expansion and facilitates proper re-expansion of the lung on the side where the fluid was removed. It is essential to follow this positioning to optimize outcomes and minimize risks associated with the procedure.
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Which is a common childhood communicable disease that may cause severe defects in the fetus when it occurs in its congenital form?
- A. Erythema infectiosum
- B. Roseola
- C. Rubeola
- D. Rubella
Correct Answer: D
Rationale: Rubella is a common childhood communicable disease that can cause severe defects in the fetus when a pregnant woman contracts the infection, leading to congenital rubella syndrome. This syndrome can result in various abnormalities in the developing fetus, such as hearing loss, vision problems, heart defects, and intellectual disabilities. Rubella is particularly dangerous when contracted during the first trimester of pregnancy, leading to a higher risk of complications for the unborn child. Therefore, Rubella is a significant public health concern due to its potential impact on fetal development and the importance of vaccination to prevent its spread.
A 4-year-old weighing 15 kg produces 150 mL of urine in 10 hours. What should the nurse do?
- A. Notify the physician; urine output is too low.
- B. Encourage increased oral intake.
- C. Record the urine output in the chart.
- D. Administer IV fluids to rehydrate.
Correct Answer: C
Rationale: Expected urine output is 0.5-1 mL/kg/hr. For a 15-kg child over 10 hours, 75-150 mL is within normal limits.
Which organ(s) is/are most at risk for dysfunction in a patient with a potassium level of 6.3 mEq/L?
- A. Lungs
- B. Liver
- C. Kidneys
- D. Heart
Correct Answer: D
Rationale: A potassium level of 6.3 mEq/L indicates hyperkalemia, which can have significant effects on the heart. The heart is one of the most sensitive organs to changes in potassium levels. In hyperkalemia, elevated serum potassium levels can lead to various cardiac manifestations, including dysrhythmias, conduction abnormalities, and eventually cardiac arrest. Monitoring and managing potassium levels are crucial in preventing life-threatening cardiac complications in patients with hyperkalemia. While the kidneys and other organs can also be affected by high potassium levels, the heart is the most critical organ to consider in this scenario.
A nurse is conducting a teaching session for parents of infants. The nurse explains that which behavior indicates that an infant has developed object permanence?
- A. Recognizes familiar face, such as mother
- B. Recognizes familiar object, such as bottle
- C. Actively searches for a hidden object
- D. Secures objects by pulling on a string
Correct Answer: C
Rationale: Object permanence is the understanding that objects continue to exist even when they can't be seen, heard, or touched. When an infant actively searches for a hidden object, it demonstrates that the infant has developed object permanence. This behavior implies that the infant understands that the object still exists even though it is temporarily out of sight. This usually emerges around 8-12 months of age, according to Piaget's theory of cognitive development. The other choices do not specifically relate to the concept of object permanence as directly as actively searching for a hidden object does.
The child begins to understand right and left by age of
- A. 3 yr
- B. 4 yr
- C. 5 yr
- D. 6 yr
Correct Answer: C
Rationale: Understanding right and left typically develops around age 5.