Nokea
While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially?
- A. Activate the code blue or emergency system
- B. Do nothing because acrocyanosis is normal in the neonate
- C. Immediately take the newborn's temperature according to hospital policy
- D. Notify the physician of the need for a cardiac consult
Correct Answer: B
Rationale: Acrocyanosis is a normal finding in newborns, characterized by bluish discoloration of the hands and feet due to immature circulation. It usually resolves on its own within 24 hours after birth and does not require any intervention. It is essential for the nurse to recognize this normal physiological process to avoid unnecessary interventions. Activating the code blue system, taking the newborn's temperature immediately, or notifying the physician of the need for a cardiac consult is not indicated in this scenario because acrocyanosis is a benign condition in neonates.
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The ductus arteriosus is another fetal structure that is important in the intrauterine life. It functions to:
- A. Shunts the combined cardiac output from the pulmonary artery to the aorta going to the lungs
- B. Shunts the combined cardiac output from the pulmonary artery to the systemic circulation
- C. Shunts the combined cardiac output from the aorta to the pulmonary artery and later to the pulmonary veins
- D. Shunts the combined cardiac output from the aorta to the pulmonary artery to the right ventricle 48
Correct Answer: B
Rationale: The ductus arteriosus is a fetal blood vessel that connects the pulmonary artery to the aorta. Its main function is to bypass the non-functional fetal lungs by shunting blood from the pulmonary artery (which carries deoxygenated blood) directly to the systemic circulation, specifically the aorta. This allows oxygenated blood from the placenta to be distributed to the body's organs and tissues without having to first pass through the lungs for oxygen exchange. After birth, when the baby begins to breathe and oxygenate its blood through the lungs, the ductus arteriosus normally closes within the first few days to weeks of life.
Mr. Reyea complains of hearing ringing noises. The nurse recognizes that this assessment suggests injury of the
- A. Frontal lobe
- B. Six cranial nerve (abducent)
- C. Occipital lobe
- D. Eight Cranial Nerve (Vestibulocochlear)
Correct Answer: D
Rationale: The eighth cranial nerve is the vestibulocochlear nerve, which is responsible for transmitting auditory and balance information from the inner ear to the brain. Complaints of hearing ringing noises, also known as tinnitus, suggest a dysfunction or injury to the vestibulocochlear nerve. Tinnitus is a common symptom of various inner ear disorders such as noise-induced hearing loss, Meniere's disease, or acoustic neuroma. Therefore, the nurse should investigate further for possible issues related to the vestibulocochlear nerve when a patient reports hearing ringing noises.
The physical abuse of children by parents affects children of all ages. It is estimated that 1% to 2% of children are physically abused during childhood and that significant number of them are fatally injured each year. Of the following, the second LEADING cause of mortality from physical abuse is
- A. rib fractures
- B. head trauma
- C. abdominal injury
- D. hot tap water burn
Correct Answer: B
Rationale: Head trauma is a leading cause of mortality in abused children, as it can result in severe brain damage or death.
A 45-year-old patient has a long- standing history of allergies to pollen. Which of the following actions indicates that the patient does not understand how to control this disease?
- A. Staying indoors on dry, windy days.
- B. Refusing to walk outside in the spring.
- C. Driving in the care with the windows open.
- D. Working in the garden on sunny days.
Correct Answer: C
Rationale: Driving in the car with the windows open is not a recommended action for someone with allergies to pollen. Keeping the windows closed while driving can help minimize exposure to pollen particles in the air. By driving with the windows open, the individual is increasing their exposure to pollen and not effectively controlling their allergy symptoms. Staying indoors on dry, windy days (Choice A), refusing to walk outside in the spring (Choice B), and working in the garden on sunny days (Choice D) are all actions that demonstrate understanding of how to control allergies to pollen by avoiding potential triggers.
The nurse is preparing to administer a unit of blood to a client's who's anemic. After its removal from the refrigerator, the blood should be administered within:
- A. 1 hour
- B. 4 hours
- C. 2 hours
- D. 6 hours
Correct Answer: B
Rationale: After blood is removed from the refrigerator, it should be administered within 4 hours. Blood should be stored in a controlled temperature environment to prevent bacterial growth and to maintain its effectiveness. In order to minimize the risk of bacterial contamination, it is important for the nurse to adhere to the recommended time frame for administering blood products. Administering the blood within 4 hours helps ensure its safety and effectiveness for the client.