A 3-month-old infant has a hypercyanotic spell. The nurse’s first action should be which of the following?

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Question 1 of 5

A 3-month-old infant has a hypercyanotic spell. The nurse’s first action should be which of the following?

Correct Answer: D

Rationale: The correct answer is D: Place child in the knee-chest position. This is the first action to relieve hypercyanotic spells in infants with Tetralogy of Fallot. Placing the child in the knee-chest position increases systemic vascular resistance, reduces venous return to the heart, and improves pulmonary blood flow. This helps alleviate the cyanosis by decreasing the right-to-left shunting of blood. Assessing for neurologic defects (A) is not the priority in this situation. Preparing the family for imminent death (B) is premature and not appropriate as the first action. Beginning cardiopulmonary resuscitation (C) is not indicated unless the infant becomes unresponsive.

Question 2 of 5

Examples of pathogens that cause human disease include:

Correct Answer: D

Rationale: The correct answer is D because all bacteria, viruses, and fungi are examples of pathogens that can cause human disease. Bacteria (choice A) such as Streptococcus and Staphylococcus can lead to infections like pneumonia and meningitis. Viruses (choice B) like Influenza and HIV cause illnesses such as the flu and AIDS. Fungi (choice C) such as Candida can result in fungal infections like yeast infections. Therefore, the correct answer includes all possible types of pathogens that can harm human health.

Question 3 of 5

Which of the following describes the flow of lymph through a lymph node draining an infected tissue?

Correct Answer: C

Rationale: The correct answer is C because the flow of lymph through a lymph node draining an infected tissue follows this pathway: afferent lymphatic vessel (brings lymph into the node) → lymph node (where lymph is filtered) → efferent lymphatic vessel (carries filtered lymph out of the node). This sequence ensures that lymph containing pathogens or antigens from the infected tissue enters the lymph node for immune response activation and filtering before being circulated back into the bloodstream. Choice A is incorrect because it reverses the order of the lymphatic vessels, leading to the lymph node first and then out of the node. Choice B is incorrect because it introduces a venule before the lymph node, which is not part of the typical lymphatic pathway. Choice D is incorrect because it introduces an artery before the lymph node, which is not part of the lymphatic circulation pathway.

Question 4 of 5

A nurse is providing care to a client who comes to the Emergency Department with a very large cut on their leg which is bleeding. The nurse explains that the healthcare team will assist with stopping the bleeding and to assist the body with wound healing. Which of the following responses would be correct for the nurse to share with the client? (Select one that does not apply.)

Correct Answer: A

Rationale: The correct answer is A because vasodilation widens blood vessels, increasing blood flow and potentially worsening bleeding. Vasoconstriction, as mentioned in option B, would help decrease bleeding by narrowing blood vessels. Option C is correct as the body forms a clot through the process of coagulation. Option D is incorrect as clot formation is not related to immunity. Therefore, the nurse should explain that the body may vasoconstrict to decrease bleeding, not vasodilate as in option A.

Question 5 of 5

Which comment from the nurse demonstrates an understanding of aplastic anemia?

Correct Answer: D

Rationale: The correct answer is D because aplastic anemia is primarily caused by autoimmune activity where cytotoxic T cells target and destroy hematopoietic stem cells in the bone marrow. This leads to pancytopenia and hypocellular, not hypercellular, bone marrow. Choice A is incorrect because aplastic anemia is not the most common type of anemia. Choice B is incorrect because it can also be caused by factors other than medications and toxins. Choice C is incorrect as it describes the opposite of the characteristic bone marrow finding in aplastic anemia.

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