Nokea
which of the following is the primary objective of care for the child with nephrosis?
- A. reduce blood pressure.
- B. reduce excretion of urinary protein.
- C. increase excretion of urinary protein.
- D. increase ability of tissues to retain fluid.
Correct Answer: B
Rationale: The primary objective of care for a child with nephrosis, also known as nephrotic syndrome, is to reduce the excretion of urinary protein. Nephrosis is a condition characterized by excessive loss of protein through the urine, leading to hypoalbuminemia and edema. By reducing the excretion of urinary protein, healthcare providers aim to minimize protein loss and improve the child's nutritional status and overall health. This can be achieved through medications such as corticosteroids, diuretics, and other treatments that help to decrease proteinuria and manage symptoms associated with nephrosis. Additionally, dietary modifications and monitoring for complications such as infection and thrombosis are important aspects of care for children with nephrosis.
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Nurse Beverly is giving preoperative instructions to Ian who is scheduled for an Ileostomy. Which of the following would be included?
- A. "Your urine will be collected in a pouch following surgery."
- B. "You will have a nasogastric tube after surgery."
- C. "Your bowel will be visualized with a laparoscope during surgery."
- D. "You can drink liquids within 24 hours after surgery."
Correct Answer: A
Rationale: An ileostomy is a surgical procedure that involves creating a stoma from the ileum (part of the small intestine) to the abdominal wall, allowing waste to bypass the colon and exit the body through the stoma into a pouch worn on the outside of the body. Therefore, it is important for Nurse Beverly to inform Ian that his stool output will be collected in a pouch following the surgery. Option A is the correct choice as it directly relates to the postoperative care and management specific to an ileostomy procedure.
Which of the ff does the examiner note when auscultating the lungs of a client with pleural effusion?
- A. Pronounced breath sounds
- B. Expiratory wheezes
- C. Friction rub
- D. Fluid in the involved area
Correct Answer: D
Rationale: When auscultating the lungs of a client with pleural effusion, the examiner would note sounds consistent with fluid accumulation in the pleural space. This includes decreased or absent breath sounds over the area where the effusion is present. The presence of fluid in the involved area may cause a dullness to percussion as well. Pronounced breath sounds and expiratory wheezes are not typically associated with pleural effusion. While a friction rub may be heard in conditions such as pleurisy, it is not specific to pleural effusion.
Which is most descriptive of the clinical manifestations observed in neonatal sepsis?
- A. Seizures and sunken fontanels
- B. Sudden hyperthermia and profuse sweating
- C. Decreased urinary output and frequent stools
- D. Nonspecific physical signs with hypothermia
Correct Answer: D
Rationale: Neonatal sepsis is a serious condition in newborns that is challenging to diagnose due to nonspecific and variable clinical signs. Some of the common manifestations of neonatal sepsis include poor feeding, lethargy, unstable temperature (hypothermia or hyperthermia), respiratory distress, apnea, irritability, and jaundice. The presence of hypothermia is often noted in neonatal sepsis, but it is essential to keep in mind that clinical signs can be subtle and nonspecific in these cases. Seizures, sudden hyperthermia, profuse sweating, decreased urinary output, and frequent stools are less specific to neonatal sepsis and may be seen in other conditions as well. Regular monitoring, prompt evaluation, and appropriate treatment are crucial in managing neonatal sepsis due to the nonspecific nature of its clinical presentation.
A client's IV fluid orders for 24 hour's are 1500 ml D5W followed by 1250 ml of NS. The IV tubing has a drop factor of 15 gtt/ml. To administer the required fluids the nurse should set the drip rate at;
- A. 13 gtt/min
- B. 29 gtt/min
- C. 16 gtt/min
- D. 32 gtt/min Situation 5: Protection of self and patient can be done by supporting the body's immunity.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
An 8-month-old infant has a hypercyanotic spell while blood is being drawn. What is the priority nursing action?
- A. Assess for neurologic defects
- B. Place the child in the knee-chest position
- C. Begin cardiopulmonary resuscitation
- D. Prepare family for imminent death
Correct Answer: B
Rationale: When an 8-month-old infant has a hypercyanotic spell, the priority nursing action is to place the child in the knee-chest position. This position helps to increase venous return to the heart and improve systemic circulation, which can relieve the cyanosis by decreasing right-to-left shunting of blood. Placing the child in the knee-chest position helps optimize oxygenation and circulation, which is crucial during a hypercyanotic spell. Assessing for neurologic defects, beginning cardiopulmonary resuscitation, or preparing the family for imminent death are not the priority actions during a hypercyanotic spell in this scenario.