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What is the first action the nurse should take?
- A. Start an IV lines for fluids
- B. Get an ECG
- C. Place a Foley catheter
- D. Check for neurologic status
Correct Answer: D
Rationale: The first action the nurse should take is to check for neurologic status. This is essential in assessing the patient's level of consciousness, orientation, motor function, and pupil responses. It helps determine if the patient is experiencing neurological issues such as a stroke, which would require immediate medical attention. Checking neurologic status is a priority because it guides the nurse in identifying the next steps for the patient's care.
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The first permanent tooth to erupt is
- A. central incisor at 6 yr
- B. molar at 6 yr
- C. premolar lower canine at 6-7 yr
- D. upper canine at 6-7 yr
Correct Answer: B
Rationale: The first permanent molar typically erupts around 6 years.
The nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
- A. Breast self-examination
- B. Fine needle aspiration
- C. Mammography
- D. Chest x-ray
Correct Answer: B
Rationale: A diagnosis of breast cancer is confirmed through a biopsy, which involves removing a sample of tissue or cells from the lump in the breast and examining it under a microscope. Fine needle aspiration is a minimally invasive procedure where a thin needle is used to remove cells from the lump for examination. This diagnostic method allows for the confirmation of breast cancer by analyzing the cells for signs of malignancy. While breast self-examinations, mammography, and chest x-rays are important tools for detecting breast abnormalities, they are not definitive in confirming a diagnosis of breast cancer.
What is the pathophysiologic mechanism of cystic fibrosis leading to obstructive lung disease?
- A. Fibrosis of mucous glands and destruction of bronchial walls
- B. Destruction of lung parenchyma from inflammation and scarring
- C. Production of secretions low in sodium chloride and therefore thickened mucus
- D. Increased serum levels of pancreatic enzymes that are deposited in the bronchial mucosa
Correct Answer: C
Rationale: Cystic fibrosis (CF) is caused by mutations in the CFTR gene, leading to altered transport of sodium and chloride ions in and out of epithelial cells. This results in the production of secretions that are low in sodium chloride, leading to thickened mucus. The abnormally thick, abundant secretions from mucous glands in the respiratory tract can obstruct the airways, leading to chronic, diffuse obstructive pulmonary disease in almost all patients with CF. This process impairs mucociliary clearance, predisposing individuals to recurrent lung infections, inflammation, and ultimately bronchiectasis. This mechanism is a key factor in the pathophysiology of cystic fibrosis-associated obstructive lung disease.
When evaluating a client's response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organ is;
- A. Urinary output of 30 ml in an hour
- B. Central venous pressure reading of 2 cm H20
- C. Pulse rates of 120 and 110 in a 15- minute period
- D. Blood pressure readings of 50/30 and 70/40 mm Hg within 30 minutes
Correct Answer: A
Rationale: The observation that indicates adequate tissue perfusion to vital organs is a urinary output of 30 ml in an hour. Adequate tissue perfusion is essential to ensure that vital organs receive enough blood and oxygen. Monitoring urinary output is a crucial indicator of perfusion status, as it reflects the perfusion of the kidneys. A urinary output of at least 30 ml/hour or more indicates that the kidneys are receiving sufficient blood flow and are able to produce urine, which helps in removing waste products from the body. In this case, a urinary output of 30 ml in an hour suggests adequate tissue perfusion to vital organs. The other options do not directly reflect tissue perfusion to vital organs and may indicate inadequate perfusion or compromised hemodynamic status.
Which is an important consideration for the nurse when changing dressings and applying topical medication to a child's abdomen and leg burns?
- A. Apply topical medication with clean hands.
- B. Wash hands and forearms before and after dressing change.
- C. If dressings adhere to the wound, soak in hot water before removal.
- D. Apply dressing so that movement is limited during the healing process.
Correct Answer: B
Rationale: Washing hands and forearms before and after a dressing change is crucial for maintaining proper hygiene and preventing the spread of infection. This practice helps to reduce the risk of introducing harmful microorganisms to the burn wounds, which could lead to complications. It is important for the nurse to wash their hands and forearms thoroughly using proper hand hygiene techniques before touching the child's wounds or applying topical medications. By following the principles of infection control, the nurse can help promote proper wound healing and prevent potential complications in the child's recovery process.