Nokea
Why should the nurse closely monitor a client to ensure that the venous access device remains in the vein during a transfusion?
- A. It minimizes the risk of phlebitis
- B. It minimizes the risk of circulatory overload
- C. It minimizes the risk of pulmonary
- D. It minimizes the risk of localized edema embolism
Correct Answer: D
Rationale: Keeping the venous access device securely in the vein during a transfusion is important to minimize the risk of localized edema embolism. If the device dislodges and infiltrates into surrounding tissues, it can lead to localized swelling, pain, and potential complications such as tissue damage. Monitoring ensures proper placement and function of the device, reducing the risk of complications related to dislodgment.
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Stroking the newborn's cheek along the side of the mouth causes the newborn to turn the head toward that side and begin to suck. This is which reflex?
- A. Perez
- B. Sucking
- C. Rooting
- D. Extrusion
Correct Answer: C
Rationale: The described reflex involving stroking the newborn's cheek along the side of the mouth causing the newborn to turn the head toward that side and begin to suck is known as the rooting reflex. This reflex is essential for newborns to find the nipple and start breastfeeding. Stroking the cheek triggers the baby to turn towards the stimulus, helping them locate the source of food for feeding.
Which is now referred to as the "new morbidity"?
- A. Limitations in the major activities of daily living
- B. Unintentional injuries that cause chronic health problems
- C. Discoveries of new therapies to treat health problems
- D. Behavioral, social, and educational problems that alter health
Correct Answer: D
Rationale: The term "new morbidity" is now used to describe the impact of behavioral, social, and educational factors on health outcomes. This concept acknowledges that health is not solely determined by physical health conditions but also by one's behaviors, social circumstances, and education levels. Factors such as smoking, substance abuse, stress, lack of education, poverty, and social inequalities can significantly influence an individual's health. Recognizing and addressing these non-traditional health determinants are crucial in promoting overall health and well-being.
The nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes highest priority?
- A. Disturbed body image related to changes in body functions
- B. Ineffective airway clearance related to obstruction by a tumor or secretions
- C. Anxiety related to actual threat to health status and changes in family dynamics
- D. Imbalanced nutrition: Less than body requirements related to anorexia and vomiting secondary to chemotherapy
Correct Answer: B
Rationale: In caring for a client with bronchogenic carcinoma, the highest priority nursing diagnosis would be Ineffective airway clearance related to obstruction by a tumor or secretions. This is crucial because any blockage in the airway can lead to serious respiratory complications, such as respiratory distress or respiratory failure. Ensuring effective airway clearance is essential to maintain adequate oxygenation and ventilation for the client. Addressing this priority nursing diagnosis promptly can help prevent potential life-threatening situations and promote optimal respiratory function for the client.
You are evaluating a 6-year-old male child with Langerhans cell histiocytosis (LCH); the parents state that the most common site of bone involvement is
- A. skull
- B. vertebra
- C. mandible
- D. pelvis
Correct Answer: A
Rationale: Skull is the most common site of bone involvement in LCH.
The nurse is developing a teaching plan for a patient. Which of the following is a modifiable risk factor for the development of hypertension? i.Race iv.Sedentary lifestyle ii.High cholesterol v.Age iii.Cigarette smoking
- A. 1 and 2
- B. 2, 3, 4 and 5
- C. 2, 3 and 4
- D. All of the above
Correct Answer: C
Rationale: High cholesterol, cigarette smoking, and a sedentary lifestyle are modifiable risk factors for the development of hypertension. Race and age are non-modifiable risk factors. By targeting high cholesterol, cigarette smoking, and promoting physical activity, the nurse can help the patient reduce their risk of developing hypertension. It is important to focus on these modifiable factors in the teaching plan to empower the patient to make positive lifestyle changes and improve their overall health.