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Which of the ff nursing interventions should a nurse perform to relieve tachycardia that may develop in a client with myocarditis from hypoxemia?
- A. Maintain the client on bed rest c.Elevate the clients head
- B. Administer a prescribed anti pyretic
- C. Administer supplemental oxygen
Correct Answer: C
Rationale: Administering supplemental oxygen is the most appropriate nursing intervention to relieve tachycardia that may develop in a client with myocarditis from hypoxemia. Myocarditis can lead to decreased oxygen delivery to the tissues, which may result in tachycardia as the body tries to compensate for the lack of oxygen. Providing supplemental oxygen will help increase oxygen levels in the blood, improving tissue perfusion and thus reducing the tachycardia. This intervention aims to address the underlying cause of the tachycardia in this situation.
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The laboratory results of a patient with disseminated intravascular coagulation are likely to include:
- A. decreased levels of fibrin split products.
- B. increased levels of fibrinogen.
- C. increased platelet counts.
- D. prolonged prothrombin and partial thromboplastin times.
Correct Answer: D
Rationale: DIC leads to prolonged clotting times due to consumption of clotting factors and platelets.
Which of the following conditions is suspected?
- A. Anemia
- B. Rheumatic arthritis
- C. Leukemia
- D. Systematic Lupus Erythematosus (SLE)
Correct Answer: C
Rationale: Leukemia is a type of cancer that affects the blood and bone marrow, leading to an overproduction of abnormal white blood cells. The symptoms of leukemia can include fatigue, weakness, weight loss, frequent infections, fever, bruising or bleeding easily, and bone pain. Given the vague presenting symptoms and the potential involvement of multiple bodily systems, leukemia is a condition that should be suspected and investigated further. Anemia, rheumatic arthritis, and systematic lupus erythematosus can also present with some similar symptoms, but for the given scenario, leukemia is the most probable condition to suspect.
When caring for a child that has undergone a tonsillectomy, the nurse should do which of the following?
- A. Observe for continuous swallowing.
- B. Encourage gargling with warm saline water.
- C. Apply warm compresses to the throat.
- D. Apply cold compresses to the throat.
Correct Answer: A
Rationale: When caring for a child that has undergone a tonsillectomy, the nurse should observe for continuous swallowing. Continuous swallowing may indicate bleeding, and it is important to monitor for this postoperatively as it can be a sign of hemorrhage, which is a potential complication following a tonsillectomy. Encouraging the child to take sips of clear fluids can help in assessing if there is bleeding. Observing for any signs of bleeding, such as frequent swallowing, along with monitoring vital signs and overall assessment, is crucial during the initial postoperative period.
In fetal period, all are true EXCEPT
- A. 10 weeks - midgut returns to abdomen
- B. 12 weeks - external genitalia formed
- C. 24 weeks - surfactant production begun
- D. 26 weeks - face clearly recognizable
Correct Answer: D
Rationale: Face recognition typically occurs earlier than 26 weeks.
Which is the primary treatment for hypoglycemia in newborns with feeding intolerance?
- A. Oral glucose feedings
- B. Intravenous (IV) infusion of glucose
- C. Short-term insulin therapy
- D. Feedings (formula or breast milk) at least every 2 hours
Correct Answer: B
Rationale: Newborns with hypoglycemia and feeding intolerance typically require immediate treatment to rapidly raise their blood glucose levels. In such cases, the primary treatment is intravenous (IV) infusion of glucose because it provides a quick and direct source of glucose for the baby's body. IV glucose administration bypasses the need for digestion, making it the most effective way to increase blood sugar levels rapidly in newborns with feeding intolerance and hypoglycemia. It is crucial to monitor the baby's blood glucose levels closely during IV glucose infusion to ensure proper management.