Nokea
Which type of neuron transmits impulses from the central nervous system to the muscles and glands?
- A. Afferent
- B. Efferent
- C. Affective
- D. Effective
Correct Answer: B
Rationale: The correct answer is B: Efferent. Efferent neurons transmit signals from the central nervous system to muscles and glands, controlling movement and secretion. Afferent neurons carry signals from sensory receptors to the central nervous system, not towards muscles or glands. "Affective" relates to emotions, not neural function. "Effective" does not describe the direction of signal transmission in the nervous system. Therefore, B is the correct choice.
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Which of the following IV solutions is hypertonic?
- A. Normal saline
- B. 0.45% NaCl
- C. 5% dextrose in 0.9% NaCl
- D. 0.225% NaCl
Correct Answer: C
Rationale: The correct answer is C: 5% dextrose in 0.9% NaCl. This solution is hypertonic because it has a higher osmolarity compared to the other choices. The presence of dextrose and NaCl in this solution increases its solute concentration, causing water to move out of the cells by osmosis. Normal saline (A) and 0.45% NaCl (B) are isotonic solutions, meaning they have the same osmolarity as body fluids. 0.225% NaCl (D) is a hypotonic solution with lower osmolarity than body fluids.
A nurse completes a thorough database and carries out nursing interventions based on priority diagnoses. Which action will the nurse take next?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: D
Rationale: The correct answer is D: Evaluation. After implementing nursing interventions based on priority diagnoses, the nurse must evaluate the effectiveness of these interventions to determine if the desired outcomes have been achieved. Evaluation is crucial to assess the progress, make necessary modifications, and ensure the effectiveness of the care provided. Assessment (A) is already completed before interventions are carried out. Planning (B) involves developing a care plan based on assessment findings. Implementation (C) is the actual carrying out of the interventions. Therefore, the next step after implementing nursing interventions is to evaluate their effectiveness.
During thoracentesis, which of the following nursing intervention will be most crucial?
- A. Place patient in a quiet and cool room
- B. Maintain strict aseptic technique
- C. Advice patient to sit perfectly still during needle insertion until it has been withdrawn from the chest
- D. Apply pressure over the puncture site as soon as the needle is withdrawn
Correct Answer: B
Rationale: The correct answer is B: Maintain strict aseptic technique. This is crucial during thoracentesis to prevent infection. Step 1: Before the procedure, sterile equipment and supplies must be used. Step 2: Proper hand hygiene is essential to reduce the risk of introducing pathogens. Step 3: During the procedure, maintaining a sterile field helps minimize the risk of contamination. Step 4: After the procedure, ensuring proper disposal of all used supplies prevents the spread of infection.
Summary:
A: Placing the patient in a quiet and cool room may be comforting but is not directly related to the safety of the procedure.
C: Advising the patient to sit still is important for accurate needle insertion but does not address infection prevention.
D: Applying pressure over the puncture site is important but does not prevent infection if aseptic technique is not maintained.
The nurse will monitor J.E. for the following signs and symptoms:
- A. Change in the levei of consciousness, tachypnea, tachycardia, petechiae
- B. Onset of chest pain, tachycardia, diaphoresis, nausea and vomiting
- C. Loss of consciousness, bradycardia, petechiae, and severe leg pain
- D. Change in leve! of consciousness, bradycardia, chest pain and oliguria
Correct Answer: A
Rationale: The correct answer is A.
1. Change in level of consciousness is crucial in assessing neurological status.
2. Tachypnea indicates possible respiratory distress or oxygenation issues.
3. Tachycardia may suggest a cardiovascular problem or inadequate perfusion.
4. Petechiae can be a sign of bleeding disorders or sepsis.
Option B is incorrect because chest pain, diaphoresis, and nausea/vomiting are more indicative of a cardiac event rather than monitoring for J.E.'s signs and symptoms.
Option C is incorrect because loss of consciousness, bradycardia, and leg pain do not align with the signs and symptoms to monitor for J.E.
Option D is incorrect because bradycardia, chest pain, and oliguria are not as comprehensive as the signs and symptoms listed in option A for monitoring J.E.
A client is receiving methotrexate (Mexate), 12g/m2 IV to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells?
- A. Probenecid (Benemid)
- B. Cytarabine (ara-C, cystosine arabinoside [Cytosar-U])
- C. Thioguanine (6-thioguanine, 6-TG)
- D. Leucovorin (Citrovorum factor or folinic acid [wellcovirin])
Correct Answer: D
Rationale: The correct answer is D: Leucovorin. Leucovorin is given during methotrexate therapy to protect normal cells by acting as a rescue agent that helps to reduce the toxic effects of methotrexate. It works by enhancing the efficacy of methotrexate in cancer cells while reducing its toxicity in normal cells. Probenecid (A) is not used to protect normal cells during methotrexate therapy. Cytarabine (B) and Thioguanine (C) are other chemotherapeutic agents and are not typically given to protect normal cells during methotrexate therapy.