Nokea
Which of the ff factors predisposes a client to the development of TB?
- A. Exposure to toxic gases
- B. Congenital abnormalities
- C. Obstruction by tumor
- D. Malnutrition
Correct Answer: D
Rationale: Malnutrition predisposes a client to the development of Tuberculosis (TB) because a lack of proper nutrition weakens the immune system, making the individual more susceptible to infections such as TB. Adequate nutrition is essential for maintaining a healthy immune system that can effectively fight off pathogens. Malnourished individuals are less able to mount a strong immune response, thus increasing their vulnerability to contracting TB and experiencing more severe symptoms and complications from the disease.
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A client receives a sealed radiation implant to treat cervical cancer. When caring for this client, the nurse should:
- A. Consider the client's urine, feces, and vomitus to be highly radioactive
- B. Consider the client to be radioactive for 10 days after implant removal
- C. Allow soiled linens to remain in the room until after the client is discharged
- D. Maintain the client on complete bed rest with bathroom privileges only
Correct Answer: B
Rationale: When caring for a client who has received a sealed radiation implant to treat cancer, it is important to consider the client to be radioactive for a certain period of time. Typically, the client is considered radioactive for about 10 days after the implant is removed. During this time, precautions should be taken to limit exposure to radiation, including following the principles of time, distance, and shielding. It is important for healthcare providers to wear appropriate protective gear when caring for the client and to limit the time spent in close proximity to the client. After the radioactive period has passed, the client will no longer be considered radioactive, and standard precautions can be followed.
A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing intervention is the most important?
- A. Immediately stop the transfusion, infuse dextrose 5% in water (D5W), and call the physician.
- B. Slow the transfusion and monitor the client closely.
- C. Stop the transfusion, notify the blood bank, and administer antihistamines
- D. Immediately stop the transfusion, infuse normal saline solution, notify the blood bank
Correct Answer: D
Rationale: In the case of an acute hemolytic reaction during a blood transfusion, the most important nursing intervention is to immediately stop the transfusion and infuse normal saline solution. This is crucial to prevent further complications associated with the hemolysis of red blood cells. Normal saline helps maintain blood pressure and support kidney function, which may be compromised during a hemolytic reaction. Additionally, notifying the blood bank is important to investigate and prevent future reactions, and to determine if there was an error in blood compatibility. Administering antihistamines or changing the fluid type (such as dextrose 5% in water) will not address the underlying issue of hemolysis and may not be the most appropriate interventions in this scenario.
A nurse is directed to administer a hypotonic intravenous solution. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms except:
- A. O.45% sodium chloride
- B. 5% dextrose in water
- C. O.90% sodium chloride
- D. 5% dextrose in normal saline solution
Correct Answer: C
Rationale: Hypotonic solutions have lower osmolarity compared to the intracellular fluid, causing water to move into the cells by osmosis. This can lead to further swelling of the cells in the body. In the case of hypovolemia, the body is already experiencing a deficit of fluid and electrolytes, so administering a hypotonic solution like 0.90% sodium chloride would further exacerbate cellular swelling and potentially lead to cellular damage. Therefore, using 0.90% sodium chloride as a compensatory mechanism for hypovolemia would not be appropriate.
When a patient participates in a research study, the pediatric nurse's primary concern is to ensure that the:
- A. parent or guardian has given verbal consent for the patient's participation.
- B. quality of care that the patient receives will not be affected if the patient chooses to withdraw from the study.
- C. research meets the developmental needs of the patient.
- D. research will directly benefit the patient.
Correct Answer: B
Rationale: Ensuring that the quality of care remains unaffected regardless of the patient's participation status is paramount to ethical research practices.
A 50-year-old African American patient is diagnosed with anemia. Where can the nurse assess for pallor?
- A. Scalp
- B. Chest
- C. Axillae
- D. Conjunctivae
Correct Answer: D
Rationale: When assessing for pallor in a patient with anemia, the nurse should specifically look at the conjunctivae (the membranes that cover the white part of the eyes). In individuals with anemia, the lack of red blood cells can result in paleness in the conjunctivae, which can be observed as a pale or whitish color. This area is especially useful for assessing pallor in individuals with darker skin tones, such as African Americans, where pallor may be less noticeable on other areas of the body.