Nokea
Which common side effect of metolazone (Zaroxolyn) should the nurse instruct a patient to report to the health- care provider?
- A. Numb hands
- B. Gastrointestinal distress
- C. Muscle weakness
- D. Nightmares
Correct Answer: C
Rationale: Metolazone, a diuretic medication commonly known as Zaroxolyn, can cause electrolyte imbalances in the body, particularly low potassium levels which can lead to muscle weakness. Therefore, the nurse should instruct the patient to report any signs or symptoms of muscle weakness to the healthcare provider promptly. Numb hands, gastrointestinal distress, and nightmares are not common side effects of metolazone that typically require urgent medical attention.
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A mother requests that her child receive the varicella vaccine at the 9-month checkup. The nurse's best response is:
- A. Vaccinated children will likely develop a mild case of chickenpox.
- B. The varicella vaccine is not usually administered before 1 year of age.
- C. The vaccine will be given after the doctor examines your child.
- D. A booster will be needed at 18 months.
Correct Answer: B
Rationale: The varicella vaccine is typically not given until the child is 12 months or older.
which of the following must be present in order for an infant with complete transposition of the great vessels to survive at birth?
- A. coarctation of aorta
- B. pulmonary stenosis
- C. patent ductus arteriosus
- D. mitral stenosis
Correct Answer: C
Rationale: In an infant with complete transposition of the great vessels, the survival at birth depends on the presence of a patent ductus arteriosus (PDA) to allow mixing of oxygenated and deoxygenated blood. In this condition, the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle, leading to separate circulatory pathways for oxygenated and deoxygenated blood. The survival of the infant is dependent on the remaining fetal shunts, such as a PDA, to maintain an adequate mixing of blood until corrective surgery can be performed. Therefore, the presence of a PDA is essential for the survival of an infant with complete transposition of the great vessels at birth.
Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:
- A. Obtain vita! Signs
- B. Assess the pain further
- C. Stop the transfusion
- D. Increase the flow of normal saline SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Correct Answer: C
Rationale: Lumbar pain during a blood transfusion can be a sign of an adverse reaction, such as a transfusion reaction. Any complaints of pain during a transfusion should not be ignored. In this case, the nurse should first stop the transfusion to prevent any further complications. The client should be assessed promptly for other signs of a transfusion reaction, and appropriate actions should be taken as needed to ensure the client's safety and well-being.
A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Which of the following assessment findings would the nurse expect to note during the assessment of this newborn?
- A. Sleepiness
- B. Cuddles when being held
- C. Lethargy
- D. Incessant crying
Correct Answer: C
Rationale: Newborn infants born to mothers who are addicted to drugs are at risk for neonatal abstinence syndrome (NAS) due to drug withdrawal. Lethargy is a common finding in newborns with NAS. This is characterized by excessive sleepiness, decreased responsiveness, and lack of energy or enthusiasm for activities. Lethargy is often seen as a result of the withdrawal symptoms experienced by the newborn due to exposure to drugs in utero. It is important for the nurse to monitor the newborn closely for signs of withdrawal and provide appropriate care and interventions to manage NAS symptoms.
These facts are true regarding the developmental stage of preschool children EXCEPT
- A. handedness is achieved by 3 years of age
- B. boys are usually later than girls in achieving bladder control
- C. knowing gender by 4 years
- D. egocentric thinking
Correct Answer: D
Rationale: Egocentric thinking is characteristic of preschool-age children.