When you report on duty, your team leader tells you that Mr. MartineHi accidentally received 1000 ml of fluids in 2 hours and that you are to be alert for signs of circulatory overload. Which of the following signs would not be likely to occur?

Correct Answer: C

Rationale: Circulatory overload is a condition where there is an excessive volume of fluid circulating in the bloodstream. Signs of circulatory overload include moist gurgling respirations, distended neck veins, dyspnea, and coughing. A weak, slow pulse would not be a typical sign of circulatory overload; in fact, it could indicate other conditions such as bradycardia or hypovolemia. Therefore, a weak, slow pulse would not likely occur as a sign of circulatory overload in this scenario.

Correct Answer: D

Rationale: The most appropriate nursing intervention in this situation is to keep the newborn's body available for a few hours in case the parents change their minds. It is important to respect the parents' feelings and fears while also providing them with the opportunity to hold their child if they decide to do so later on. By keeping the newborn's body available, the parents can have the time and space they need to process their emotions and make a decision that feels right for them. This approach supports the parents' autonomy and allows them to grieve in a way that is meaningful to them.

Correct Answer: D

Rationale: Leucovorin, also known as folinic acid, is given concurrently with methotrexate therapy to protect normal cells from the toxic effects of methotrexate. Methotrexate is a folate antagonist that affects both cancer cells and normal cells. Leucovorin is a reduced form of folic acid that bypasses the enzyme targeted by methotrexate, allowing normal cells to continue using folate for DNA synthesis. This rescue therapy helps prevent or reduce the side effects of methotrexate, such as mucositis, myelosuppression, and other toxic effects on normal cells. It is important to administer leucovorin at the appropriate times following methotrexate administration to maximize its protective effect while maintaining the efficacy of the chemotherapy.

Correct Answer: D

Rationale: Scarlet fever is caused by Group Aß-hemolytic streptococci (GABHS), particularly Streptococcus pyogenes. This bacteria produces erythrogenic exotoxins that cause the characteristic rash seen in scarlet fever. These toxins also contribute to the other symptoms associated with scarlet fever, such as high fever, sore throat, and a red, bumpy tongue (strawberry tongue). Therefore, the correct causative agent of scarlet fever is Group Aß-hemolytic streptococci (GABHS).

Correct Answer: B

Rationale: An advantage of peritoneal dialysis is that protein loss is less extensive compared to hemodialysis. Peritoneal dialysis operates by using the peritoneal membrane in the abdomen to act as a natural filter, helping to remove waste products and excess fluids from the body. The process of peritoneal dialysis allows for a slower, more continuous removal of waste substances, which results in reduced protein loss as compared to hemodialysis. This can be beneficial for maintaining overall nutritional status and preventing complications related to protein deficiencies in patients undergoing dialysis treatment.