Nokea
A patient reports on admission being "very sick" after taking erythromycin in the past. The patient is to receive erythromycin now. Which of the following actions should the nurse take regarding giving the antibiotic?
- A. Give the antibiotic
- B. Do not give the antibiotic
- C. Give half of the dose
- D. Discontinue the antibiotic
Correct Answer: B
Rationale: In this scenario, the patient reports being "very sick" after taking erythromycin in the past, indicating a history of adverse reaction to the medication. Given this information, it would be most prudent to withhold the erythromycin to prevent a potential adverse reaction or worsening of the patient's condition. It is important for the nurse to always consider the patient's previous experiences and adverse reactions when administering medications to ensure patient safety.
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Within 20 minutes of the start of transfusion, the client develops a sudden fever. What is the nurse's first action?
- A. Force fluids
- B. Increase the flow rate of IV fluids
- C. Continue to monitor the vitals signs
- D. Stop the transfusion
Correct Answer: D
Rationale: The sudden onset of fever early in a blood transfusion can indicate a transfusion reaction, such as a febrile non-hemolytic reaction or a hemolytic reaction. The nurse's first action in this situation should be to stop the transfusion immediately to prevent further complications. Continuing to administer the blood product could worsen the reaction and harm the client. Once the transfusion is stopped, the nurse can then assess the client's condition, provide appropriate interventions, and notify the healthcare provider as needed.
The nurse is caring for an infant with congestive heart disease (CHD). The nurse should plan which intervention to decrease cardiac demands?
- A. Organize nursing activities to allow for uninterrupted sleep.
- B. Allow the infant to sleep through feedings during the night.
- C. Wait for the infant to cry to show definite signs of hunger.
- D. Discourage parents from rocking the infant
Correct Answer: A
Rationale: Organizing nursing activities to allow for uninterrupted sleep is the most appropriate intervention to decrease cardiac demands in an infant with congestive heart disease (CHD). Providing a peaceful and quiet environment will help in conserving the infant's energy and reducing stress on the heart, ultimately decreasing cardiac demands. Interrupted sleep or inadequate rest can place additional strain on the infant's heart, leading to increased cardiac demands and potential complications. Prioritizing uninterrupted sleep will benefit the infant's overall cardiac function and well-being.
What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
- A. Wait for the patient to complete the sentence.
- B. Immediately begin showing the patient various objects In the environment.
- C. Leave the room and come back later.
- D. Begin naming various objects that the patient could be referring to.
Correct Answer: A
Rationale: It is crucial to give the patient with aphasia time to complete their sentence. Aphasia can impact a person's ability to find the right words, so allowing them the time to express themselves can be helpful. Rushing or providing excessive cues could lead to frustration and may not allow the patient the opportunity to find the appropriate words on their own. Being patient and giving the individual time to communicate can be empowering and supportive.
Which of the ff is an important nursing intervention for HIV positive clients?
- A. Suggesting the use of herbal medications and alternative therapies
- B. Suggesting the use of psychostimulants such as methamphetamine
- C. Advising the client to avoid clinical drug trials
- D. Providing referral to support groups and resources for information
Correct Answer: D
Rationale: For HIV positive clients, one of the most important nursing interventions is to provide referral to support groups and resources where they can find emotional support, information, and guidance. Support groups can offer a sense of community, a safe space to share experiences, and practical advice on living with HIV. These groups can also provide valuable resources on managing HIV, accessing treatment, and coping with any associated stigma or discrimination. By connecting HIV positive clients to support groups and resources, nurses can help them navigate the challenges of living with HIV and promote their overall well-being and quality of life. This intervention fosters a holistic approach to care that goes beyond just medical treatment to address the social, emotional, and psychological needs of the client.
Which of the ff is the most severe complication among clients with allergies, regardless of type?
- A. Bronchitis
- B. Anaphylactic shock and angioneurotic
- C. Cardiac arrest edema
- D. Asthma and nasal polyps
Correct Answer: B
Rationale: Among clients with allergies, regardless of type, anaphylactic shock and angioneurotic edema are the most severe complications. Anaphylactic shock is a severe, potentially life-threatening allergic reaction that can occur rapidly and affect multiple organ systems, leading to a sudden drop in blood pressure and difficulty breathing. Angioneurotic edema, also known as angioedema, is another serious allergic reaction that involves swelling of the deep layers of the skin, often around the eyes and lips, but can also affect the throat and other areas, potentially leading to airway obstruction. These complications require immediate medical attention, including the administration of epinephrine and other interventions to stabilize the client.