An adolescent tells the school nurse that she is pregnant. Her last menstrual period was 4 months ago. She has not received any medical care. She smokes but denies any other substance use. What is the priority nursing action?

Correct Answer: B

Rationale: The priority nursing action in this situation is to refer the adolescent for prenatal care. Prenatal care is crucial for monitoring the health of both the mother and the baby throughout the pregnancy. This includes assessing for any potential complications, providing appropriate interventions, and ensuring proper support for a healthy pregnancy. It is important for the adolescent to receive medical care as soon as possible to optimize the outcomes for both her and her baby. While notifying her parents, explaining the importance of not smoking, and discussing dietary needs are also important aspects of care, ensuring timely access to prenatal care is the most critical priority in this scenario.

Correct Answer: B

Rationale: Phimosis is the term used to describe the narrowing of the preputial opening of the foreskin in males. This condition does not allow the foreskin to be fully retracted over the head of the penis, which can cause issues with hygiene and potentially lead to infections. Phimosis can occur in newborns and also persist into adulthood if not treated. It is important for healthcare providers, including nurses, to be aware of this condition in order to provide appropriate education and intervention when needed.

Correct Answer: B

Rationale: In chronic renal disease, the kidneys are not functioning properly, leading to an accumulation of phosphorus in the body. High levels of phosphorus can be harmful and contribute to bone and mineral disorders. Calcium carbonate is often given with meals to bind phosphorus in the gut and prevent its absorption. By binding with phosphorus, calcium carbonate helps lower the levels of phosphorus in the blood, thereby managing complications associated with chronic renal disease, such as renal osteodystrophy. It is an essential part of the treatment plan for patients with chronic kidney disease to help maintain appropriate phosphorus balance in the body and prevent further complications.

Correct Answer: C

Rationale: Atrial septal defect (ASD) is a congenital heart defect where there is an abnormal opening in the atrial septum, leading to a left-to-right shunt of blood. This shunt causes increased pulmonary blood flow, as oxygenated blood from the left atrium is shunted back into the right atrium and then into the pulmonary circulation. Over time, this increased pulmonary blood flow can lead to pulmonary hypertension and potentially Eisenmenger syndrome if left untreated. Pulmonic stenosis, tricuspid atresia, and transposition of the great arteries all typically result in decreased pulmonary blood flow rather than increased pulmonary blood flow.

Correct Answer: C

Rationale: Administering analgesics before removing chest tubes from a child is an important nursing consideration because the procedure may cause pain or discomfort. While it is ideal to minimize pain during and after the removal, it is essential to anticipate the possibility of discomfort and provide appropriate pain management to ensure the child's comfort and well-being. By administering analgesics before the procedure, nurses can help alleviate any potential pain and promote a more positive experience for the child.