Nokea
With pulmonary edema, there is usually an alteration in:
- A. Afterload
- B. Preload
- C. Contractility
- D. All of the above
Correct Answer: D
Rationale: Pulmonary edema is characterized by the accumulation of excess fluid in the lungs, which can lead to impaired gas exchange and respiratory distress. In the presence of pulmonary edema, there is usually an alteration in all three factors mentioned: afterload, preload, and contractility.
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Mr. and Mrs. Smith's child has hemophilia; which of the following actions would you instruct them to avoid?
- A. Immobilizing the joint
- B. Lowering the injured area
- C. Applying cold to the area
- D. Applying pressure
Correct Answer: C
Rationale: Hemophilia is a condition where the blood fails to clot properly. Applying cold to the area can cause vasoconstriction (narrowing of blood vessels) which may slow down the blood flow and exacerbate the bleeding in individuals with hemophilia. Therefore, instructing Mr. and Mrs. Smith to avoid applying cold to the area of injury is crucial in order to prevent further complications.
What is the role of a nurse during scratch test to detect allergies?
- A. Applying the liquid test antigen
- B. Determining the type of allergy
- C. Measuring the length and width of the
- D. Documenting the findings raised wheal
Correct Answer: A
Rationale: During a scratch test to detect allergies, one of the key roles of a nurse is to apply the liquid test antigen onto the patient's skin. The liquid test antigen contains small amounts of common allergens that could trigger a reaction in individuals who are allergic to them. By applying the test antigen onto the skin and creating small scratches or pricks, the nurse can observe if the patient develops a raised, red, itchy bump called a wheal at the site of the allergen exposure. This helps in identifying specific allergies and determining the appropriate treatment plan for the patient.
A client is admitted to the ICU, which laboratory result must be reported immediately to the physician?
- A. Hematocrit 48%
- B. paCO2 38 mm Hg
- C. platelets 18,000
- D. WBC count 8000
Correct Answer: C
Rationale: A platelet count of 18,000 is significantly low, indicating a condition known as thrombocytopenia, which can lead to a risk of bleeding. In a critical care setting like the ICU, low platelet counts need to be addressed urgently to prevent serious complications such as hemorrhage. This result must be reported immediately to the physician so that appropriate interventions, such as transfusion of platelets, can be initiated promptly to manage the patient's condition effectively. Hematocrit, paCO2, and WBC count may also be important parameters to monitor in an ICU patient, but the critically low platelet count poses the most immediate threat to the patient's well-being and requires urgent attention.
A nurse is teaching a parent about administration of iron supplements to a 7-month-old infant. Which should the nurse include in the teaching session? (Select all that apply.)
- A. Administer the iron supplement with a dropper toward the side and to the back of the mouth
- B. Administer the iron supplement with feedings.
- C. Your infant's stools may look tarry green.
- D. Your infant may have some diarrhea initially.
Correct Answer: A
Rationale: Administer the iron supplement with a dropper toward the side and to the back of the mouth: This instruction helps ensure that the iron supplement bypasses the taste buds on the front of the tongue, which may reduce the likelihood of a strong taste causing rejection or spitting out by the infant.
What is the best age for solid food to be introduced into the infant's diet?
- A. 2 to 3 months
- B. 4 to 6 months
- C. When birth weight has tripled
- D. When tooth eruption has started
Correct Answer: B
Rationale: The American Academy of Pediatrics recommends introducing solid foods into an infant's diet between 4 to 6 months of age. At this stage, most infants have developed the necessary motor skills to start eating solid foods, such as being able to sit up and hold their head steady. Additionally, their digestive system has matured enough to handle solid foods. Introducing solid foods too early, such as at 2 to 3 months (Option A), can increase the risk of digestive issues and allergies. Waiting for tooth eruption (Option D) is not a reliable indicator as some infants may begin teething earlier or later than others. Waiting for the birth weight to triple (Option C) is not necessary as infants can start on solid foods once they reach the appropriate developmental stage around 4 to 6 months.