Nokea
Which finding might delay a cardiac catheterization procedure on a 1-year-old?
- A. 30th percentile for weight
- B. Severe diaper rash
- C. Allergy to soy
- D. Oxygen saturation of 91% on room air
Correct Answer: B
Rationale: A severe diaper rash may indicate potential infection, which is a contraindication for the standard groin approach during catheterization.
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An adult female with multiple sclerosis (MS) falls while walking to the bathroom. On transfer to the intensive care unit, she is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?
- A. Determine client's last dose of corticosteroids
- B. Determine neurological baseline prior to the fall
- C. Administer a PRN IV antiemetic as prescribed
- D. Complete head to toe neurological assessment.
Correct Answer: D
Rationale: The symptoms suggest increased intracranial pressure or a neurological emergency. A thorough neurological assessment is necessary to identify the cause and guide further interventions.
Manifestations of endocarditis include all of the following EXCEPT
- A. Gottron nodules
- B. hematuria
- C. petechiae
- D. splenomegaly
Correct Answer: A
Rationale: Gottron nodules are associated with dermatomyositis, not endocarditis.
The parents of a child, age 6, who will begin school in the fall ask the nurse for anticipatory guidance. The nurse should explain that a child of this age:
- A. Still depends on the parents
- B. Rebels against scheduled activities
- C. Is highly sensitive to criticism
- D. Loves to tattle
Correct Answer: C
Rationale: A 6-year-old child is typically highly sensitive to criticism as they are developing self-esteem and are influenced by feedback from adults and peers.
Hypothalamic nuclei are responsible for:
- A. Control of hunger
- B. Temperature control
- C. Maintaining osmolarity of extracellular fluid
- D. Secretion of thyrotrophin
Correct Answer: A
Rationale: The hypothalamus plays a key role in regulating hunger through various nuclei and hormonal signals.
A client who is receiving chemotherapy is vomiting. Which nursing intervention should the nurse implement first?
- A. Teach the client about the importance of hydration
- B. Report the volume of emesis to the healthcare provider
- C. Administer ondansetron hydrochloride (Zofran)
- D. Encourage the client to limit the amount of movement
Correct Answer: C
Rationale: Administering ondansetron (Zofran) will help relieve the vomiting and prevent dehydration, addressing the immediate concern.