Nokea
What type of breath sound is normally heard over the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium?
- A. Vesicular
- B. Bronchial
- C. Adventitious
- D. Bronchovesicular
Correct Answer: A
Rationale: Vesicular breath sounds are normal, low-pitched sounds heard over the majority of the lung surface. They are usually soft and rustling with a longer inspiratory phase than expiratory phase. Vesicular breath sounds are produced by air moving through smaller bronchioles and alveoli. These sounds can be heard over the entire lung surface except for the upper intrascapular area and the area beneath the manubrium, where bronchovesicular breath sounds are typically heard.
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The nurse is teaching parents about appropriate pacifier selection. Which characteristics should the pacifier have? (Select all that apply.)
- A. Easily grasped handle
- B. One-piece construction
- C. Ribbon or string to secure to clothing
- D. Soft, pliable material
Correct Answer: B
Rationale: B. One-piece construction: It is important for the pacifier to have a one-piece construction to prevent any choking hazards. Pacifiers that have multiple parts can break apart and pose a risk to the infant.
The entire process of toilet training need not be hurried and it can take
- A. 2 months
- B. 4 months
- C. 6 months
- D. 8 months
Correct Answer: C
Rationale: Toilet training typically takes around 6 months, though this varies from child to child.
In children diagnosed with sickle cell disease (SCD), tissue damage results from which of the following?
- A. Air hunger and respiratory alkalosis due to deoxygenated red blood cells.
- B. Hypersensitivity of the central nervous system (CNS) due to elevated serum bilirubin levels
- C. A general inflammatory response due to an autoimmune reaction from hypoxia
- D. Local tissue damage with ischemia and necrosis due to obstructed circulation
Correct Answer: D
Rationale: In children diagnosed with sickle cell disease (SCD), tissue damage results from local tissue damage with ischemia and necrosis due to obstructed circulation. Sickle cell disease is a genetic disorder characterized by abnormal hemoglobin that causes red blood cells to assume a sickle shape. These sickle-shaped cells can adhere to blood vessel walls, leading to vaso-occlusion and impaired blood flow. This obstruction results in tissue ischemia and eventual necrosis, causing significant pain and organ damage. The chronic vaso-occlusive events in SCD are responsible for the development of acute and chronic complications seen in affected individuals, such as painful crises, stroke, and organ damage.
Coarctation of the aorta causes all of the following signs except:
- A. higher B/P in the upper extremities
- B. right ventricular hypertrophy
- C. legs cooler than arms
- D. nosebleeds
Correct Answer: D
Rationale: Coarctation of the aorta is a congenital heart defect characterized by a narrowing of the aorta, the main artery carrying blood from the heart to the body. The signs of coarctation of the aorta include higher blood pressure in the upper extremities (Choice A) due to the narrowing of the aorta causing increased pressure proximal to the constriction. Right ventricular hypertrophy (Choice B) occurs as the heart works harder to overcome the obstruction in the aorta. Legs being cooler than arms (Choice C) is a result of decreased blood flow to the lower body due to the aortic narrowing. Hemodilution (Choice E) can occur as a compensatory mechanism in response to the increased blood pressure in the upper body. Nosebleeds (Choice D) are not typically associated with coarctation of the aorta but may occur due to other factors unrelated to this condition.
When performing nursing care for a neonate after a birth, which intervention has the highest nursing priority?
- A. Obtain a dextrostix
- B. Give the initial bath
- C. Give the vitamin K injection
- D. Cover the neonates head with a cap
Correct Answer: C
Rationale: The highest nursing priority when performing nursing care for a neonate after birth is giving the vitamin K injection. Vitamin K is essential for blood clotting, and neonates are born with low levels of this vitamin, putting them at risk for bleeding disorders. Administering the vitamin K injection helps prevent serious bleeding complications such as Vitamin K Deficiency Bleeding (VKDB). It is crucial to give this injection as soon as possible after birth to ensure the neonate receives adequate protection. Covering the neonate's head with a cap may help maintain body temperature but is not as critical as administering the vitamin K injection. Obtaining a dextrostix or giving the initial bath are important aspects of newborn care but do not take precedence over the administration of vitamin K.