Nokea
Which of the following actions should the nurse take?
- A. Monitor for the development of Koplik spots.
- B. Isolate the client from staff who are pregnant.
- C. Administer aspirin to the client
- D. Initiate airborne precautions
Correct Answer: B
Rationale: Pregnant women should avoid contact with individuals who have rubella due to the risk of congenital defects.
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For each finding. click to specify if the finding is consistent with pancreatitis or peritonitis Each finding may support more than one disease process.
- A. Bloody stools
- B. Hyperbilirubinemia
- C. Abdominal pain
- D. Elevated WBC court
Correct Answer: A,B,C,D
Rationale: The correct answer is .
Rationale:
1. Bloody stools can be seen in both pancreatitis and peritonitis due to gastrointestinal bleeding.
2. Hyperbilirubinemia is a common finding in pancreatitis due to obstruction of the bile duct by edema or inflammation.
3. Abdominal pain is a hallmark symptom of both pancreatitis and peritonitis, indicating inflammation or irritation of the abdominal structures.
4. Elevated WBC count is a sign of infection or inflammation, which can be present in both pancreatitis and peritonitis.
Summary:
- Bloody stools: Supports both pancreatitis and peritonitis.
- Hyperbilirubinemia: Supports pancreatitis.
- Abdominal pain: Supports both pancreatitis and peritonitis.
- Elevated WBC count: Supports both pancreatitis and peritonitis.
Other choices are incorrect because they do not align with the typical clinical presentations of pancreatitis
Which of the following interventions should the nurse include?
- A. Assess the child for frequent swallowing
- B. Carefully suction the child's oropharynx to remove secretions
- C. Administer pancreatic enzymes with meals
- D. Continuously monitor the child's respiratory status
Correct Answer: A
Rationale: Frequent swallowing indicates airway obstruction risks.
Which of the following tasks should the charge nurse assign to a licensed practical nurse?
- A. Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus.
- B. Complete the Glasgow Coma Scale for a client who has an evolving stroke.
- C. Perform a sterile dressing change for a client who has an abdominal wound.
- D. Perform an admission assessment for a client who is scheduled for surgery.
Correct Answer: C
Rationale: LPNs are trained for sterile dressing changes.
The client is at risk for developing ------- and--------
- A. Hypoglycemia
- B. bronchopulmonary dysplasia
- C. transient tachypnea of the newborn
- D. Tachycardia
Correct Answer: A, C
Rationale: The correct answer is A and C. Hypoglycemia and transient tachypnea of the newborn are common risks for newborns. Hypoglycemia can occur due to immature liver function, while transient tachypnea results from retained lung fluid. The other choices are incorrect because bronchopulmonary dysplasia is a chronic lung condition seen in premature infants, and tachycardia is a symptom of various conditions but not typically a primary risk for newborns.
Which of the following findings is the nurse's priority?
- A. Constipation
- B. Sedation
- C. Bradypnea
- D. Euphoria
Correct Answer: C
Rationale: The correct answer is C: Bradypnea. Bradypnea, or slow breathing, is a critical finding that can indicate respiratory compromise and potentially lead to respiratory failure. It requires immediate attention to prevent further deterioration.
Constipation (A) is important but not as urgent as addressing a respiratory issue. Sedation (B) and euphoria (D) are side effects that may need monitoring but do not pose immediate threats to the patient's health.
In summary, addressing bradypnea is the priority to ensure the patient's respiratory function and prevent a life-threatening situation.