Nokea
Which of the following data would be included in a health history? (Select all that apply.)
- A. Review of systems
- B. Physical assessment
- C. Sexual history
- D. Growth measurements
Correct Answer: A
Rationale: A health history is a comprehensive compilation of information about a patient's health status, medical conditions, and pertinent background information. The selected data that would be included in a health history includes:
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Which nursing intervention is appropriate for the nurse to take when setting up supplies for a client who requires a blood transfusion?
- A. Add any needed IV medication in the blood bag within one hour of planned infusion
- B. Obtain blood bag from laboratory and leave at room temperature for at least one hour prior to infusion
- C. Prime tubing of blood administration set with 0.9% NS solution, completely, filling filter
- D. Inadequate dietary intake
Correct Answer: C
Rationale: When setting up supplies for a client who requires a blood transfusion, the appropriate nursing intervention is to prime the tubing of the blood administration set with 0.9% NS solution completely, filling the filter. This is essential to ensure that the blood components flow smoothly through the tubing and any potential air bubbles are removed in order to prevent air embolism and ensure the safety of the blood transfusion process. Option A is not correct because adding IV medication in the blood bag is not a standard practice and can compromise the integrity of the blood product. Option B is also incorrect as blood products should be stored and maintained at specific temperatures to prevent spoilage or contamination; leaving it at room temperature is not advised. Option D is unrelated to setting up supplies for a blood transfusion and addresses inadequate dietary intake, which is a different nursing concern than the preparation of blood transfusion supplies.
Sunshine, age 13, has had a lumbar puncture to examine the CSF to determine if bacterial infection exists. The best position to keep her in after the procedure is:
- A. Prone for two hours to prevent aspiration, should she vomit.
- B. Semi-Fowler's so she can watch TV for five hours and be entertained.
- C. Supine for several hours, to prevent a headache.
- D. On her right sides to encourage return of CSF
Correct Answer: C
Rationale: The best position to keep Sunshine in after a lumbar puncture is in the supine position for several hours. This position helps prevent a post-lumbar puncture headache, which is a common complication of the procedure. Keeping Sunshine supine helps reduce the chances of leaking CSF and minimizes the risk of developing a headache due to decreased CSF pressure. Additionally, it is vital to encourage increased fluid intake post-procedure to help replenish the lost CSF and prevent dehydration.
Which of the following immunoglobulins is first produced during an acute infection?
- A. IgG
- B. IgE
- C. IgM
- D. IgD
Correct Answer: C
Rationale: IgM is the first immunoglobulin produced during an acute infection. It is the first class of antibodies secreted by B cells in response to an antigenic challenge. IgM antibodies are produced initially in primary immune responses and play a crucial role in activating the complement system. IgG is produced after IgM and is the most abundant immunoglobulin in the secondary immune response. IgE is responsible for allergic reactions, and IgD's function is not fully understood but is believed to be involved in the activation of B cells.
Which is most important to document about immunizations in the child's health history?
- A. Dosage of immunizations received
- B. Occurrence of any reaction after an immunization
- C. The exact date the immunizations were received
- D. Practitioner who administered the immunizations
Correct Answer: C
Rationale: The most important information to document about immunizations in a child's health history is the exact date the immunizations were received. This information is crucial for tracking when the child is due for their next immunizations and to ensure they are following the recommended vaccination schedule. The dosage of immunizations received, occurrence of any reaction after an immunization, and the practitioner who administered the immunizations are also important details to document but the most critical one is the date to accurately maintain the vaccination records and plan future immunization appointments.
Which finding would you expect in a 4-week-old with biliary atresia?
- A. Abdominal distention, enlarged liver and spleen, clay-colored stools, and tea-colored urine.
- B. Abdominal distention with bruises and hematuria.
- C. Yellow sclera/skin, oily skin, and prolonged bleeding times.
- D. No manifestations until advanced disease.
Correct Answer: A
Rationale: Biliary atresia typically presents with hepatosplenomegaly, pale stools, and dark urine due to impaired bile excretion.