Nokea
Which of the following is the function of macrophages and neutrophils?
- A. Phagocytosis
- B. Complement fixation
- C. Antibody production
- D. Suppression of autoimmunity
Correct Answer: A
Rationale: The correct answer is A: Phagocytosis. Macrophages and neutrophils are both types of phagocytes responsible for engulfing and digesting pathogens such as bacteria. This process helps in clearing infections and maintaining immune homeostasis.
Summary:
- Choice B (Complement fixation) is incorrect as it refers to a process where complement proteins bind to pathogens to enhance their removal by phagocytes.
- Choice C (Antibody production) is incorrect as macrophages and neutrophils do not produce antibodies. They mainly rely on phagocytosis for pathogen clearance.
- Choice D (Suppression of autoimmunity) is incorrect as these cells are involved in innate immunity and do not play a direct role in regulating autoimmunity.
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A client with acquired immunodeficiency syndrome (AIDS) is receiving zidovudine (azidothymidine, AZT [Retrovir]). To check for adverse drug effects, the nurse should monitor the results of laboratory test?
- A. RBC count
- B. Serum calcium
- C. Fasting blood glucose
- D. Platelet count
Correct Answer: D
Rationale: The correct answer is D: Platelet count. Zidovudine (AZT) is known to cause bone marrow suppression, leading to decreased platelet production. Monitoring platelet count is crucial to detect early signs of thrombocytopenia, a common adverse effect of AZT.
Rationale:
A) RBC count: AZT can cause anemia, not specifically affecting the RBC count.
B) Serum calcium: AZT does not typically affect calcium levels.
C) Fasting blood glucose: AZT can cause hyperglycemia, but fasting blood glucose monitoring is not as critical as monitoring platelet count for AZT therapy.
A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)
- A. Patient’s temperature
- B. Patient’s wound appearance
- C. Patient describing excitement about discharge
- D. Patient pacing the floor while awaiting test results
Correct Answer: C
Rationale: The correct answer is C because subjective data refers to information reported by the patient, such as their feelings, emotions, and perceptions. In this case, the patient describing excitement about discharge is an example of subjective data. The other choices (A, B, D) are objective data because they are observable and measurable by the nurse. Temperature (A) and wound appearance (B) are physical observations, while the patient pacing the floor (D) is a behavior that can be observed. It is important for nurses to differentiate between subjective and objective data to provide accurate assessments and care for their patients.
Which of the ff nursing interventions may reduce hemostasis and decrease the potential for thrombophlebitis for a client with a neurologic disorder?
- A. Remove and reapply elastic stockings
- B. Keep extremities at neutral position
- C. Change the clients position
- D. Use a flotation mattress NEUROMUSCULAR DISORDERS
Correct Answer: B
Rationale: The correct answer is B: Keep extremities at neutral position. This intervention promotes proper blood flow and reduces the risk of thrombophlebitis by preventing compression or restriction of blood vessels. Removing and reapplying elastic stockings (choice A) can disrupt circulation and increase the risk of thrombophlebitis. Changing the client's position (choice C) may not directly address hemostasis or thrombophlebitis. Using a flotation mattress (choice D) is not specifically focused on maintaining proper positioning of the extremities to promote circulation.
A client on hemodialysis is complaining of muscle weakness and numbness in his legs. His lab results are: Na 136 mEq/L, K 5.9 mEq/L, Cl 100 mEq/L, ca 8.5 mg/dl. Which electrolyte imbalance is the client suffering from?
- A. Hyperkalemia
- B. Hypocalcemia
- C. Hypernatremia
- D. Hypochloremia
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. In hemodialysis, potassium levels can be elevated due to impaired renal excretion. High potassium can lead to muscle weakness and numbness. The client's K level of 5.9 mEq/L is above the normal range (3.5-5.0 mEq/L), confirming hyperkalemia. Na, Cl, and Ca levels are within normal limits, ruling out hypernatremia, hypochloremia, and hypocalcemia as the client's primary electrolyte imbalance. Monitoring and managing hyperkalemia are crucial to prevent life-threatening complications like cardiac arrhythmias.
Victorio is being managed for diarrhea. Which outcome indictes that fluid resuscitation is successful?
- A. he passess formed stools at regular intervals
- B. he reports a decrease in stool frequency and liquidity
- C. he exhibits frim skin turgor
- D. he no longer experiences perianal burning
Correct Answer: C
Rationale: The correct answer is C because firm skin turgor indicates adequate hydration, a key goal of fluid resuscitation in diarrhea management. Firm skin turgor reflects the body's fluid balance and hydration status. When fluid resuscitation is successful, the patient's skin turgor improves due to replenished fluid levels. Choices A, B, and D are incorrect as they do not directly assess hydration status or the effectiveness of fluid resuscitation. Passing formed stools, decrease in stool frequency, and absence of perianal burning may be positive outcomes in diarrhea management, but they do not specifically indicate successful fluid resuscitation.