Which system is primarily affected by tuberculosis (Mycobacterium)?
- A. stomach (GI)
- B. heart (cardiac)
- C. lungs (respiratory)
- D. skin (integumentary)
Correct Answer: C
Rationale: Tuberculosis, caused by Mycobacterium tuberculosis, primarily affects the respiratory system. This aerobic bacillus thrives in highly oxygenated body sites, such as the lungs, growing ends of bones, and the brain. The bacillus is airborne, making the lungs a common site for infection. Choices A, B, and D are incorrect as tuberculosis predominantly impacts the respiratory system and rarely involves the stomach, heart, or skin.
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At what age will vision be 20/20 in children?
- A. 4 years old
- B. 5 years old
- C. 6 years old
- D. 7 years old
Correct Answer: C
Rationale: The correct answer is 6 years old. At this age, children typically have the potential for 20/20 vision. This is considered the standard age for achieving optimal vision clarity. Choices A, B, and D are incorrect as they are not typically associated with the age at which children achieve 20/20 vision.
A client receiving drug therapy with furosemide and digitalis requires careful observation and care. In planning care for this client, the nurse should recognize that which of the following electrolyte imbalances is most likely to occur?
- A. hyperkalemia
- B. hypernatremia
- C. hypokalemia
- D. hypomagnesemia
Correct Answer: C
Rationale: When a client is receiving drug therapy with furosemide and digitalis, the nurse should anticipate the development of hypokalemia due to the potassium-wasting effects of furosemide. Hypokalemia can potentiate digitalis toxicity. While hyperkalemia is a concern with some medications, it is not typically associated with furosemide and digitalis. Furosemide can lead to hyponatremia, not hypernatremia, due to its diuretic effect. Hypomagnesemia, though a possible imbalance, is not the most likely to occur in this scenario as furosemide and digitalis are more commonly associated with hypokalemia.
A 46-year-old has returned from a heart catheterization and wants to get up to start walking 3 hours after the procedure. The nurse should:
- A. Tell the patient to remain with the leg straight for at least another hour and check the chart for activity orders.
- B. Allow the patient to begin limited ambulation with assistance.
- C. Recommend a physical therapy consultation for ambulation.
- D. Tell the patient to remain with the leg straight for another 6 hours and check the chart for activity orders.
Correct Answer: A
Rationale: The correct answer is to tell the patient to remain with the leg straight for at least another hour after a heart catheterization before starting ambulation. This period allows for proper healing and reduces the risk of complications such as bleeding or hematoma formation at the catheter insertion site. Starting ambulation too soon can disrupt the healing process and lead to adverse events. Choice B is incorrect because limited ambulation should not be initiated shortly after the procedure as it may increase the risk of complications. Choice C is incorrect as physical therapy consultation is not typically necessary for initial ambulation post-heart catheterization; this can be managed by nursing staff. Choice D is incorrect as keeping the leg straight for 6 hours is excessive and unnecessary, potentially leading to complications such as deep vein thrombosis due to prolonged immobility.
An infection in a central venous access device is not eliminated by giving antibiotics through the catheter. How might bacterial glycocalyx contribute to this?
- A. It protects the bacteria from antibiotic and immunologic destruction.
- B. Glycocalyx neutralizes the antibiotic, rendering it ineffective.
- C. It competes with the antibiotic for binding sites on the microbe.
- D. Glycocalyx provides nutrients for microbial growth.
Correct Answer: A
Rationale: Bacterial glycocalyx is a viscous polysaccharide or polypeptide slime that covers microbes. It plays a significant role in protecting bacteria by enhancing adherence to surfaces, resisting phagocytic engulfment by white blood cells, and preventing antibiotics from contacting the microbe. Choice A is correct because glycocalyx shields the bacteria from both antibiotics and the immune system, allowing the infection to persist. Choices B, C, and D are incorrect because glycocalyx does not neutralize antibiotics, compete for binding sites with antibiotics, or provide nutrients for microbial growth.
A nurse working in a surgical unit notices a patient experiencing SOB, calf pain, and warmth over the posterior calf. All of these symptoms may indicate which of the following medical conditions?
- A. Patient may have a DVT.
- B. Patient may be exhibiting signs of dermatitis.
- C. Patient may be in the late stages of CHF.
- D. Patient may be experiencing anxiety after surgery.
Correct Answer: A
Rationale: The correct answer is that the patient may have a DVT (Deep Vein Thrombosis). SOB (Shortness of Breath), calf pain, and warmth over the posterior calf are classic signs and symptoms of DVT. DVT is a serious condition where a blood clot forms in a deep vein, commonly in the legs. Choices B, C, and D are incorrect because dermatitis does not typically present with these symptoms, late stages of CHF would manifest with other signs, and anxiety after surgery usually does not produce these specific symptoms.