Nokea
While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. what is the etiology of this problem?
- A. Irritation of nerve endings
- B. Diminished blood flow
- C. Ischemic tissue changes
- D. Compression of a nerve
Correct Answer: D
Rationale: Carpal tunnel syndrome is caused by compression of the median nerve, leading to pain and other symptoms.
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Causes of non-bloody diarrhoea include:
- A. Shigella dysentery
- B. Campylobacter jejuni
- C. Giardia lamblia
- D. Salmonella
Correct Answer: C
Rationale: Giardia lamblia is a common cause of non-bloody diarrhoea. Shigella and Campylobacter typically cause bloody diarrhoea.
The nurse is finishing her shift on the pediatric unit. Because her shift is ending, which intervention takes top priority?
- A. Changing the linens on the clients’ beds
- B. Restocking the bedside supplies needed for a dressing change on the upcoming shift
- C. Documenting the care provided during her shift
- D. Emptying the trash cans in the assigned client room
Correct Answer: C
Rationale: Documenting care is a legal and professional responsibility that ensures continuity of care and accurate communication between shifts.
SA 14-14-2 Vaccine for Japanese encephalitis is
- A. Live attenuated
- B. Vero cell derived inactivated
- C. Mouse-brain derived inactivated
- D. Live recombinant
Correct Answer: A
Rationale: The SA 14-14-2 vaccine is a live attenuated vaccine used for Japanese encephalitis.
The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess urine output?
- A. Inserting a foley catheter.
- B. Weighing the diapers.
- C. Comparing intake with output.
- D. Measuring the amount of water added to the formula.
Correct Answer: B
Rationale: Weighing diapers is a non-invasive and accurate method to assess urine output in infants, which is crucial for monitoring the effectiveness of diuretic therapy.
Seventy-two hours after cardiac surgery, a young child has a temperature of 101° F. Which action should the nurse take?
- A. Keep child warm with blankets.
- B. Apply a hypothermia blanket.
- C. Record temperature on nurses’ notes.
- D. Report findings to physician.
Correct Answer: D
Rationale: In the first 24 to 48 hours after surgery, the body temperature may increase to 37.7° C (100° F) as part of the inflammatory response to tissue trauma. If the temperature is higher or continues after this period, it is most likely a sign of an infection and immediate investigation is indicated. Blankets should be removed from the child to keep the temperature from increasing. Hypothermia blanket is not indicated for this level of temperature. The temperature should be recorded, but the physician must be notified for evaluation. Suctioning should be done only as indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at one time. Symptoms of respiratory distress are avoided by using appropriate technique.