Nokea
Which finding would alert a nurse that a hospitalized 6-year-old child is at risk for a severe asthma exacerbation?
- A. Oxygen saturation of 95%
- B. Mild work of breathing
- C. Absence of intercostals or substernal retractions
- D. History of steroid-dependent asthma
Correct Answer: D
Rationale: A history of steroid-dependent asthma indicates severe asthma, increasing the risk of a life-threatening exacerbation.
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Through what does the infant born with hypoplastic left heart syndrome acquire oxygenated blood?
- A. The patent ductus arteriosus
- B. A ventricular septal defect
- C. The closure of the foramen ovale
- D. An atrial septal defect
Correct Answer: D
Rationale: Because the right side of the heart must take over pumping blood to both the lungs and systemic circulation, the ductus arteriosus must remain open to shunt the oxygenated blood from the lungs.
A client returns to the unit following a suprapubic prostatectomy. He has a three-way catheter in place with a continuous bladder irrigation infusing. Which assessment finding warrants immediate intervention by the nurse?
- A. True urinary output of 50ml/hr
- B. Lower abdominal tenderness
- C. Blood urine output with clots
- D. Urine leaking around the meatus
Correct Answer: D
Rationale: Urine leaking around the meatus may indicate catheter displacement or obstruction, requiring immediate attention to prevent complications.
Blueberry muffin' lesions seen in rubella is due to
- A. Dermal erythropoiesis
- B. Thrombocytopenia
- C. Ecchymosis
- D. Vasculitis
Correct Answer: A
Rationale: Blueberry muffin' lesions in congenital rubella are due to dermal erythropoiesis, where extramedullary hematopoiesis occurs in the skin.
Of the following, the cardiac lesion resulting in increased volume load is
- A. valvular pulmonic stenosis
- B. patent ductus arteriosus
- C. valvular aortic stenosis
- D. mitral stenosis
Correct Answer: B
Rationale: Patent ductus arteriosus leads to increased volume load on the left side of the heart.
A nurse assesses a client who is recovering from a myocardial infarction. The client’s pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first?
- A. Compare the results with previous pulmonary artery pressure readings.
- B. Increase the intravenous fluid rate because these readings are low.
- C. Immediately notify the health care provider of the elevated pressures.
- D. Document the finding in the client’s chart as the only action.
Correct Answer: A
Rationale: Comparing the current pulmonary artery pressure readings with previous ones helps determine if the values are stable or changing, which guides further intervention.