Question

The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this level of injury?

Answer 1

Correct Answers:

Respiratory compromise

Rationale :

💁‍♂️An injury at the C3 spinal level severely affects the diaphragm and intercostal muscles, leading to respiratory failure.

💨The phrenic nerve, which innervates the diaphragm, originates from C3 to C5, and damage at this level compromises spontaneous breathing.

⚠️Clients with high cervical injuries often require mechanical ventilation due to impaired respiratory muscle function.

👃Respiratory compromise is the leading cause of morbidity and mortality in these clients, not bradycardia or sepsis initially.

📌Core Message

High cervical spinal injuries like at C3 lead to respiratory compromise due to diaphragmatic paralysis.

Answer 2

Correct Answers:

Assess daily for redness. swelling or exudate at insertion site weekly

Rationale :

🩹Tunneled catheters such as a Hickman line increase the risk of central line-associated bloodstream infections (CLABSI).

🧼Clients must be taught to perform daily site assessments for signs of infection, such as redness, swelling, or discharge.

❌Increased urine output is not an infection sign, and flushing is typically done more frequently than weekly to maintain patency.

📋Routine blood work monitoring does not replace the need for daily physical site inspection.

📌Core Message

Daily assessment of tunneled catheter sites is critical to detect early signs of infection such as redness or exudate.

Answer 3

Correct Answers:

13.7

Rationale :

⚖️Convert 121 lbs to kg: 121 ÷ 2.2 = 55 kg.

🧮Dose ordered = 1 mg/kg × 55 kg = 55 mg.

💉Medication supply = 40 mg per 10 mL → 55 mg × (10 ÷ 40) = 13.75 mL, rounded to 13.7 mL.

📏Accurate dose calculation is crucial in IV push administration to ensure patient safety.

📌Core Message

Correctly calculating IV doses requires weight conversion and adjusting to the supplied concentration.

Answer 4

Correct Answers:

Alopecia
Epistaxis

Rationale :

🩸Acute lymphocytic leukemia (ALL) often presents with bleeding signs like epistaxis (nosebleeds) due to thrombocytopenia.

💇‍♀️Alopecia is a side effect of chemotherapy, not an initial finding of leukemia itself.

❌Ascites and generalized edema are more typical of liver or kidney conditions, not leukemia.

🔬Early ALL signs typically include fatigue, fever, infections, and bleeding manifestations.

📌Core Message

Initial signs of ALL may include epistaxis due to low platelets and alopecia as a treatment side effect.

Answer 5

Correct Answers:

Use of intravenous substances

Rationale :

🦠Infective endocarditis is commonly caused by bacterial entry into the bloodstream, especially from IV drug use.

💉The use of contaminated needles can introduce organisms directly into circulation, leading to valve infection.

📋Past surgeries or hypertension are not direct causes unless they involve prosthetic valves or indwelling devices.

🩺IV drug use is a key risk factor and must always be assessed in clients with suspected endocarditis.

📌Core Message

IV substance use significantly increases risk for infective endocarditis by introducing bacteria into the bloodstream.

Answer 6

Correct Answers:

Assess the respiratory status hourly and as needed
Ensure that a manual resuscitation bag is at the bedside
Collaborate frequently with the respiratory therapist

Rationale :

💁‍♂️Ventilated clients require frequent respiratory assessments to monitor for complications like ventilator-associated pneumonia.

🧯A manual resuscitation bag must always be kept at the bedside in case of ventilator malfunction or emergency disconnection.

🤝Collaboration with respiratory therapists ensures optimal ventilator settings and oxygen delivery.

❌Pulse checks once per shift and adjusting based on consciousness are not appropriate respiratory interventions.

📌Core Message

Care of ventilated clients requires frequent assessments, backup equipment, and interdisciplinary collaboration.

Answer 7

Correct Answers:

A heart murmur

Rationale :

💁‍♂️Mitral valve stenosis causes turbulent blood flow through the narrowed valve, resulting in a diastolic murmur.

🩺The murmur is best heard at the apex of the heart, especially with the client in the left lateral position.

❌Barrel chest is associated with COPD, not valve disorders.

👉Clubbing and bradycardia are not hallmark signs of mitral stenosis.

📌Core Message

Mitral stenosis leads to a diastolic murmur due to restricted blood flow through the mitral valve.

Answer 8

Correct Answers:

The earlier the age of sexual activity and the more partners, the greater the risk

Rationale :

🧬Cervical cancer is strongly linked to human papillomavirus (HPV) infection, which is more likely with early sexual debut and multiple partners.

💡These behaviors increase exposure risk to HPV, the most significant risk factor for cervical malignancy.

❌Pap smears detect precancerous changes but do not prevent cancer; and rhinovirus has no connection to cervical cancer.

🍽️Diet and birth control use have no strong evidence directly linking them to cervical cancer development.

📌Core Message

Early sexual activity and multiple partners elevate risk of cervical cancer due to increased HPV exposure.

Answer 9

Correct Answers:

PH of 7.21 (normal 7.35-7.45)

Rationale :

🧪A pH of 7.21 indicates acidosis, often a sign of shock and impaired perfusion, which are life-threatening after trauma.

🩸Metabolic or lactic acidosis occurs from tissue hypoxia and anaerobic metabolism, indicating systemic deterioration.

❌A heart rate of 130 is compensatory, and while abnormal, not as life-threatening as severe acidosis.

🧍‍♂️Other values (platelets, potassium) are abnormal but less urgent predictors of early death than low pH.

📌Core Message

A low pH (acidosis) after trauma reflects shock and predicts early death from systemic hypoperfusion.

Answer 10

Correct Answers:

respiratory alkalosis

Rationale :

🧾A pH of 7.51 indicates alkalosis, and a PaCO₂ of 28 mmHg confirms it is respiratory in origin.

🌬️The lungs are blowing off too much CO₂, which is common in hyperventilation scenarios like anxiety or early sepsis.

🧠The bicarbonate (HCO₃) is normal, ruling out metabolic causes.

📉This ABG pattern points to respiratory alkalosis, not acidosis or metabolic imbalance.

📌Core Message

A high pH with low PaCO₂ indicates respiratory alkalosis, typically from hyperventilation.

1 :
The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this level of injury?

2 :
The nurse is preparing discharge teaching for a client newly diagnosed with cancer who just had a tunneled IV catheter (Hickman) placed. The nurse would include which information in the teaching plan regarding sign and symptoms of infection?

3 :
A patient is ordered 1 mg/kg of furosemide IV push. The patient weights 121 lbs. The medication is supplied 40 mg/10 mL. How many mL should the nurse administer? (round to the nearest tenth)

4 :
Which initial assessment findings would the nurse expect in a client diagnosed with acute lymphocytic leukemia ALL? (Select all that apply)

5 :
The nurse is caring for a client with infectious endocarditis. Which information obtained from the health history could have contributed to the development of the disease progress?

6 :
The client Is in the intensive care unit on a ventilator. Which intervention(s) should the nurse implement? (Select all that apply)

7 :
A nurse is assessing a client who has mitral valve stenosis. Which of the following findings should the nurse except?

8 :
A client in the gynecology clinic asks the nurse, "What are the risk factors for developing cervical cancer?" Which statement by the nurse is the best response?

10 :
The client's arterial blood gases reveal the following results; pH 7.51. Pa02 80 mmHg, PaC02 28 mmHg, HC03-24 mEq/L. 02 saturation 92%. The nurse interprets this blood gas result as?

1 : The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this level of injury?

2 : The nurse is preparing discharge teaching for a client newly diagnosed with cancer who just had a tunneled IV catheter (Hickman) placed. The nurse would include which information in the teaching plan regarding sign and symptoms of infection?

3 : A patient is ordered 1 mg/kg of furosemide IV push. The patient weights 121 lbs. The medication is supplied 40 mg/10 mL. How many mL should the nurse administer? (round to the nearest tenth)

4 : Which initial assessment findings would the nurse expect in a client diagnosed with acute lymphocytic leukemia ALL? (Select all that apply)

5 : The nurse is caring for a client with infectious endocarditis. Which information obtained from the health history could have contributed to the development of the disease progress?

6 : The client Is in the intensive care unit on a ventilator. Which intervention(s) should the nurse implement? (Select all that apply)

7 : A nurse is assessing a client who has mitral valve stenosis. Which of the following findings should the nurse except?

8 : A client in the gynecology clinic asks the nurse, "What are the risk factors for developing cervical cancer?" Which statement by the nurse is the best response?

10 : The client's arterial blood gases reveal the following results; pH 7.51. Pa02 80 mmHg, PaC02 28 mmHg, HC03-24 mEq/L. 02 saturation 92%. The nurse interprets this blood gas result as?

1 :
The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this level of injury?

2 :
The nurse is preparing discharge teaching for a client newly diagnosed with cancer who just had a tunneled IV catheter (Hickman) placed. The nurse would include which information in the teaching plan regarding sign and symptoms of infection?

3 :
A patient is ordered 1 mg/kg of furosemide IV push. The patient weights 121 lbs. The medication is supplied 40 mg/10 mL. How many mL should the nurse administer? (round to the nearest tenth)

4 :
Which initial assessment findings would the nurse expect in a client diagnosed with acute lymphocytic leukemia ALL? (Select all that apply)

5 :
The nurse is caring for a client with infectious endocarditis. Which information obtained from the health history could have contributed to the development of the disease progress?

6 :
The client Is in the intensive care unit on a ventilator. Which intervention(s) should the nurse implement? (Select all that apply)

7 :
A nurse is assessing a client who has mitral valve stenosis. Which of the following findings should the nurse except?

8 :
A client in the gynecology clinic asks the nurse, "What are the risk factors for developing cervical cancer?" Which statement by the nurse is the best response?

10 :
The client's arterial blood gases reveal the following results; pH 7.51. Pa02 80 mmHg, PaC02 28 mmHg, HC03-24 mEq/L. 02 saturation 92%. The nurse interprets this blood gas result as?