Nokea
Which of the ff vessels is often used for grafting?
- A. The basic and cephalic veins in the arm
- B. The internal mammary and internal thoracic arteries in the chest
- C. The saphenous vein in the leg
- D. The radial artery in the arm
Correct Answer: B
Rationale: The correct answer is B because the internal mammary and internal thoracic arteries in the chest are commonly used for grafting due to their size, durability, and long-term patency. These arteries have a better track record for successful grafting procedures compared to the other options. The basic and cephalic veins in the arm (Option A) are typically used for venous procedures, not arterial grafting. The saphenous vein in the leg (Option C) is also commonly used for grafting, but the internal mammary and internal thoracic arteries are preferred for their better outcomes. The radial artery in the arm (Option D) is less commonly used for grafting compared to the internal mammary and internal thoracic arteries.
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The thymus gland role with the immune system is which of the following?
- A. Maturates B cells
- B. Maturates platelets
- C. Maturates red blood cells
- D. Maturates T cells
Correct Answer: D
Rationale: The correct answer is D: Maturates T cells. The thymus gland is crucial for the maturation of T cells, a type of white blood cell that plays a central role in the adaptive immune response. T cells mature in the thymus through a process of selection and education, where they learn to distinguish self from non-self antigens. This process is essential for the development of a functional immune system. Choices A, B, and C are incorrect because the thymus gland does not play a role in the maturation of B cells, platelets, or red blood cells, respectively.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will prescribe diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client does not comply with the recommended treatment, which complication may arise?
- A. Cerebral edema
- B. Severe hyperkalemia
- C. Hypovolemic shock
- D. Tetany
Correct Answer: A
Rationale: Correct Answer: A - Cerebral edema
Rationale:
1. SIADH leads to water retention and dilutional hyponatremia.
2. Diuretic therapy aims to increase urine output and correct fluid imbalance.
3. If the client does not comply, excessive water retention can lead to cerebral edema.
4. Cerebral edema is a serious complication that can cause neurological deficits.
Summary:
- B: Severe hyperkalemia is unlikely as diuretics would help excrete excess potassium.
- C: Hypovolemic shock is not expected as fluid restriction may prevent rapid volume loss.
- D: Tetany is not a direct consequence of non-compliance with treatment for SIADH.
Mr. Mariano was on his way home from a party. Apparently, he got drunk and lost his balance and suffered a vehicular accident. Upon arrival at the hospital, the nurse noticed that his only injury is an open fracture of the left humerus. Which assessment finding by the nurse is critical?
- A. status of client’s tetanus immunization
- B. current blood alcohol level
- C. support systems available at home to assist with care
- D. last time client voided
Correct Answer: A
Rationale: The correct answer is A: status of client’s tetanus immunization. It is critical because an open fracture poses a risk of infection, and tetanus prophylaxis is necessary to prevent tetanus infection. Tetanus is caused by a bacterium commonly found in soil and can enter the body through open wounds. Assessing the client's tetanus immunization status helps determine the need for a tetanus booster to prevent potential complications.
Incorrect choices:
B: Current blood alcohol level - While relevant to the situation, the priority in this case is preventing infection from the open fracture.
C: Support systems available at home to assist with care - Important for discharge planning but not the immediate priority.
D: Last time client voided - Not critical in this scenario compared to preventing infection from the open fracture.
A client with autoimmune thrombocytopenia and a platelet count of 8,000/ul develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, “I don’t need surgery-this will go away on its own”. In considering her response to the client, the nurse must depend on the ethical principle of:
- A. Beneficence
- B. Advocacy
- C. Autonomy
- D. Justice
Correct Answer: C
Rationale: The correct answer is C: Autonomy. Autonomy is the ethical principle that upholds an individual's right to make decisions about their own healthcare. In this scenario, the client is expressing her desire to not undergo surgery, which is her right as an autonomous individual. The nurse must respect her decision even if it goes against medical advice. Beneficence (A) is the ethical principle of doing good for the patient, but in this case, respecting the client's autonomy takes precedence. Advocacy (B) involves supporting the client's best interests, which could align with autonomy in this case. Justice (D) refers to fairness and equal treatment, but it is not directly applicable to the client's decision regarding surgery.
Which of the ff must the nurse consider when administering IV fluids to clients with hypertension?
- A. The nurse checks the clients BP every hour
- B. The nurse checks the site and progress of the infusion every hour
- C. The nurse checks the progress of the infusion once a day
- D. The nurse checks the client’s pulse rate every hour
Correct Answer: B
Rationale: The correct answer is B because monitoring the site and progress of the infusion every hour is crucial to prevent complications like infiltration or infection in clients with hypertension. Choice A is incorrect as checking BP every hour is excessive. Choice C is incorrect as daily monitoring may not detect issues promptly. Choice D is incorrect as pulse rate monitoring is not directly related to IV fluid administration in this context. Monitoring the site and progress hourly ensures timely intervention if any issues arise.