Nokea
Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain breakthrough for a morphine drip is not working?
- A. The client complains of discomfort at the IV insertion site
- B. The client states 'I just can't get relief from my pain.'
- C. The level of the drug is 100 ml at 8 AM and is 80 ml at noon
- D. The level of the drug is 100 ml at 8 AM and is 50 ml at noon
Correct Answer: C
Rationale: The correct answer is that the level of the drug is 100 ml at 8 AM and is 80 ml at noon. With a basal rate of 10 mL per hour, a total of 40 mL should have been infused by noon, leaving only 60 mL in the container. Any amount greater than 60 mL at noon indicates that the pump is not functioning properly. Therefore, the finding of 80 mL at noon suggests the pump is not delivering the expected medication volume. Choices A and B are related to the client's symptoms and may indicate the need for pain management assessment but do not specifically indicate pump malfunction. Choice D, where the level drops to 50 mL at noon, would actually indicate that the pump is working effectively, as the expected volume has been delivered.
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A patient diagnosed with alopecia would be described as having:
- A. body lice
- B. lack of ear lobes
- C. Indigestion
- D. hair loss
Correct Answer: D
Rationale: The correct answer is 'hair loss.' Alopecia is a medical term that specifically refers to the condition of hair loss, usually in patches or all over the body. Choice A, 'body lice,' refers to a parasitic infestation and is not related to alopecia. Choice B, 'lack of ear lobes,' is completely unrelated to the term alopecia, which is solely about hair loss. Choice C, 'Indigestion,' has no connection to alopecia as it pertains to digestive issues, not hair loss. Therefore, the correct description for a patient diagnosed with alopecia is 'hair loss.'
Which of these individuals would the nurse suspect as having the greatest risk of contracting Hepatitis B?
- A. A sexually active 45-year-old man who has Type 1 Diabetes
- B. A 75-year-old woman who lives in a crowded nursing home
- C. A child who lives in a country with poor sanitation and hygiene standards
- D. A sexually active 23-year-old man who works in a hospital
Correct Answer: D
Rationale: The correct answer is a sexually active 23-year-old man who works in a hospital. This individual is at the highest risk of contracting Hepatitis B due to exposure in a healthcare setting where potential bloodborne pathogens are present. Being sexually active also increases the risk of transmission through sexual contact. Choice A, a 45-year-old man with Type 1 Diabetes, is not directly associated with an increased risk of Hepatitis B. Choice B, a 75-year-old woman living in a crowded nursing home, is at risk for other infections due to the living environment but not specifically for Hepatitis B. Choice C, a child in a country with poor sanitation, is more at risk for water or foodborne illnesses rather than Hepatitis B transmission.
When is cleft palate repair usually performed in children?
- A. A cleft palate cannot be repaired in children.
- B. Repair is usually performed by age 8 weeks.
- C. Repair is usually performed by 2 months of age.
- D. Repair is usually performed between 6 months and 2 years.
Correct Answer: D
Rationale: Cleft palate repair timing is individualized based on the severity of the deformity and the child's size. Typically, cleft palate repair is performed between 6 months and 2 years of age. This age range allows for optimal outcomes and is often done before 12 months to promote normal speech development. Early closure of the cleft palate helps to facilitate speech development. Options A, B, and C are incorrect because a cleft palate can be repaired in children, and repair is usually performed between 6 months and 2 years of age, not at 8 weeks or 2 months.
In a 24-year-old woman, the term used to define uterine bleeding in which there is no menstruation is:
- A. Oligomenorrhea
- B. Amenorrhea
- C. Menorrhagia
- D. Metrorrhagia
Correct Answer: B
Rationale: Amenorrhea is the correct term for the absence of menstrual periods in a woman of childbearing age. It is typically defined as no menstruation for at least three consecutive cycles or six months. Oligomenorrhea refers to infrequent or irregular menstrual periods rather than complete absence. Menorrhagia is characterized by excessive menstrual bleeding, not the absence of menstruation. Metrorrhagia involves irregular, acyclic bleeding between menstrual periods, which is different from the absence of menstruation.
The mother of a child who had a cleft palate repair 4 days ago is receiving home care instructions. Which statement by the mother indicates the need for further instruction?
- A. ''I will use a short nipple on the bottle.''
- B. ''I should avoid using straws for drinking.''
- C. ''I can give my child the pacifier in 2 weeks.''
- D. ''I may give my baby food mixed with water.''
Correct Answer: B
Rationale: The correct answer is ''I should avoid using straws for drinking.'' After a cleft palate repair, the child should avoid straws, pacifiers, spoons, and fingers near the mouth for 7 to 10 days to prevent injury to the surgical site. Allowing the child to use a straw can create negative pressure in the mouth, potentially disrupting the healing process. The other options are appropriate postoperative instructions for a child who had a cleft palate repair and do not pose a risk to the surgical site.