Nokea
Two days after a nephrectomy, the client reports abdominal pressure and nausea, which assessment should the nurse implement?
- A. Palpate the abdomen
- B. Measure hourly urine output
- C. Ambulate client in hallway
- D. Auscultate bowel sounds
Correct Answer: D
Rationale: Auscultating bowel sounds helps assess for any bowel obstruction or ileus, which could be contributing to abdominal pressure.
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A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen?
- A. During sleep
- B. When changing the infant’s diapers
- C. When the mother is holding the infant
- D. When drawing blood for electrolyte level testing
Correct Answer: A
Rationale: Administering oxygen during sleep can help ensure the infant maintains adequate oxygenation, especially since infants with heart failure may have compromised respiratory function.
What are FOUR possible causes of left axis deviation in a newborn with features of Trisomy 21?
- A. AVSD
- B. Tricuspid atresia
- C. Pulmonary atresia with intact ventricular septum
- D. Mechanical shift
Correct Answer: A
Rationale: AVSD is a common congenital heart defect associated with Trisomy 21 and can lead to left axis deviation seen on ECG.
The child becomes unresponsive. The most likely underlying lesion is
- A. cardiomyopathy
- B. anomalous coronary artery
- C. tetralogy of Fallot
- D. constipation
Correct Answer: C
Rationale: Tetralogy of Fallot can cause hypoxic spells leading to unresponsiveness.
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.
Uncommon complications of severe falciparum malaria are:
- A. Stroke
- B. Anaemia
- C. Hepatitis
- D. Jaundice
Correct Answer: A
Rationale: The correct answer is A because stroke is an uncommon complication of severe falciparum malaria. The other options (b-e) are more common complications.