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When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. What is the best explanation for this?
- A. Some form of cancer
- B. Local scalp infection common in children
- C. Infection or inflammation distal to the site
- D. Infection or inflammation close to the site
Correct Answer: D
Rationale: In this case, the tenderness, enlargement, and warmth of the child's cervical lymph nodes are likely due to an infection or inflammation that is close to the site. When lymph nodes are palpated and found to be tender, enlarged, and warm, it often indicates that the lymphatic system is responding to an infection or inflammation in the nearby area. The lymph nodes are part of the body's immune system and can become enlarged and tender as they work to fight off the infection. In this scenario, the most likely explanation is an infection or inflammation located near the cervical lymph nodes.
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A child is playing in the playroom. The nurse needs to obtain a child's blood pressure. Which is the appropriate procedure for obtaining the blood pressure?
- A. Take the blood pressure in the playroom.
- B. Ask the child to come to the exam room to obtain the blood pressure.
- C. Ask the child to return to his or her room for the blood pressure, then escort the child back to the playroom.
- D. Document that the blood pressure was not obtained because the child was in the playroom.
Correct Answer: B
Rationale: The appropriate procedure for obtaining a child's blood pressure is to ask the child to come to the exam room to obtain the blood pressure. This is important because the exam room provides a quiet and controlled environment, which is conducive to accurately measuring blood pressure. Taking the blood pressure in the playroom may lead to inaccurate readings due to distractions and noise. Similarly, asking the child to return to his or her room for the blood pressure and then escorting the child back to the playroom is not necessary and may disrupt the child's play. Documenting that the blood pressure was not obtained because the child was in the playroom is not a valid or appropriate action as it is important to ensure the child's health and monitor their blood pressure in a suitable environment. Therefore, the best course of action is to ask the child to come to the exam room to obtain the blood pressure.
Which is a clinical manifestation of the systemic venous congestion that can occur with heart failure?
- A. Tachypnea
- B. Tachycardia
- C. Peripheral edema
- D. Pale, cool extremities
Correct Answer: C
Rationale: Peripheral edema is a common clinical manifestation of systemic venous congestion that can occur with heart failure. In heart failure, the heart is unable to pump effectively, leading to a backup of blood in the veins. This increased pressure in the veins causes fluid to leak out into the surrounding tissues, resulting in swelling or edema, most commonly in the lower extremities. Tachypnea (rapid breathing) and tachycardia (fast heart rate) are more associated with the compensatory mechanisms of the body to try to maintain cardiac output and oxygenation. Pale, cool extremities are more indicative of poor peripheral perfusion, which can occur with severe heart failure but are not the typical manifestations of systemic venous congestion.
Which of the ff is a critical task of a nurse during the uterosigmoidostomy procedure for treating a malignant tumor?
- A. Inspecting for bleeding or cyanosis
- B. Inspecting for symptoms of peritonitis
- C. Assessing the clients allergy to iodine
- D. Checking for signs of electrolyte losses
Correct Answer: A
Rationale: During a uterosigmoidostomy procedure for treating a malignant tumor, a critical task of the nurse is to inspect for bleeding or cyanosis. Bleeding can be a potential complication during surgery and needs to be promptly identified and managed by the nurse. Cyanosis, which is a bluish discoloration of the skin due to lack of oxygen, can indicate a lack of blood flow to the tissues. Both bleeding and cyanosis are serious issues that require immediate attention to prevent further complications and ensure the client's safety and well-being. Therefore, assessing and monitoring for these signs are crucial tasks for the nurse in this situation.
Which blood product replaces missing clotting factors in the patient who has a bleeding disorder?
- A. Platelets
- B. Albumin
- C. Packed RBC
- D. Cryoprecipitate
Correct Answer: D
Rationale: Cryoprecipitate is a blood product that contains concentrated amounts of clotting factors, including fibrinogen, Factor VIII, Factor XIII, and von Willebrand factor. These clotting factors are essential for the formation of blood clots, and when a patient has a bleeding disorder such as hemophilia or von Willebrand disease, cryoprecipitate is used to replace the missing or deficient clotting factors. Platelets are used to help with clot formation in cases of thrombocytopenia, albumin is used to treat low albumin levels in conditions like liver disease, and packed RBCs are used to treat anemia by providing oxygen-carrying red blood cells. However, for a patient with a bleeding disorder needing replacement of missing clotting factors, cryoprecipitate is the most appropriate blood product.
Nurse Lina gives discharge instructions to Aling Maria, who is experiencing an exacerbation of COPD because of an upper respiratory tract infection, regarding her diet at home. Which of the following food choices would be appropriate?
- A. low fat low cholesterol
- B. low sodium diet
- C. bland soft diet
- D. high calorie high protein
Correct Answer: D
Rationale: A patient experiencing an exacerbation of COPD, especially due to an infection, requires a diet that is high in calories and protein. This is because during exacerbations, the body's energy requirements increase due to increased work of breathing and inflammation. High-calorie intake helps provide the necessary energy for breathing and healing. Additionally, a high-protein diet is important for maintaining respiratory and skeletal muscle strength, which can be affected during exacerbations of COPD. Therefore, a high-calorie high-protein diet would be most appropriate for Aling Maria to support her recovery and overall health during this period.