Nokea
The nurse is developing a plan of care for the client with multiple myeloma. The nurse includes which priority intervention in the plan of care?
- A. Encourage fluid
- B. Coughing and deep breathing
- C. Providing frequent oral care
- D. Monitoring red blood cell coun
Correct Answer: B
Rationale: A priority intervention for a client with multiple myeloma is to include coughing and deep breathing exercises in the plan of care. Multiple myeloma can affect the bone marrow's ability to produce healthy blood cells, including red blood cells, which can lead to anemia. Anemia can cause fatigue and shortness of breath. By encouraging coughing and deep breathing exercises, the nurse can help improve lung function, enhance oxygenation, and prevent potential respiratory complications in the client with multiple myeloma. This intervention is crucial in promoting respiratory health and overall well-being for the client.
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The nurse should always keep which of these drugs at the bedsides of a client with myasthenia gravis
- A. Atropine
- B. Inderal
- C. Tensilon
- D. Neostigmine
Correct Answer: C
Rationale: The nurse should always keep Tensilon (Edrophonium) at the bedside of a client with myasthenia gravis. Tensilon is a fast-acting cholinesterase inhibitor that can be used for the diagnosis and emergency treatment of myasthenia crisis. It helps improve muscle strength temporarily by increasing the levels of acetylcholine at the neuromuscular junction. Administering Tensilon can help differentiate between a myasthenic crisis (marked improvement in muscle strength) and a cholinergic crisis (no improvement or worsening of muscle weakness). Keeping Tensilon at the bedside allows for prompt administration in case of a myasthenic crisis.
Which of the following actions is appropriate for managing a conscious patient with a dislocated shoulder?
- A. Attempting to reduce the dislocation by pulling on the affected arm.
- B. Applying a splint to immobilize the arm in the dislocated position.
- C. Providing analgesia and applying ice packs to the affected shoulder.
- D. Administering intravenous fluids to prevent dehydration.
Correct Answer: C
Rationale: For managing a conscious patient with a dislocated shoulder, the appropriate action is to provide analgesia to help manage the pain and discomfort associated with the dislocation. Applying ice packs to the affected shoulder can also help reduce swelling and provide some relief. It is important to refrain from attempting to reduce the dislocation by pulling on the affected arm, as this can cause further damage and worsen the injury. Applying a splint to immobilize the arm in the dislocated position is also not recommended, as this can lead to complications and hinder the reduction process. Administering intravenous fluids to prevent dehydration is not directly related to managing a dislocated shoulder in a conscious patient.
Which of the following statements accurately describes the process of opsonization during the immune response?
- A. Opsonins facilitate the lysis of target cells by forming membrane attack complexes.
- B. Opsonins promote the phagocytosis of pathogens by coating them with proteins.
- C. Opsonins neutralize toxins produced by pathogens.
- D. Opsonins stimulate the release of histamine from mast cells.
Correct Answer: B
Rationale: Opsonization is a process in the immune response where opsonins, which are proteins such as antibodies and complement proteins, bind to pathogens such as bacteria, making them more easily recognized and engulfed by phagocytic cells like macrophages and neutrophils. This coating of pathogens by opsonins enhances the efficiency of phagocytosis, helping in the elimination of pathogens from the body. Opsonins do not facilitate cell lysis, neutralize toxins, or stimulate histamine release; their main function is to tag pathogens for phagocytosis.
A patient presents with crushing chest pain that lasts longer than 20 minutes, diaphoresis, and dyspnea. An electrocardiogram (ECG) shows ST-segment elevation in the anterior leads. Which cardiovascular disorder is most likely responsible for these symptoms?
- A. Stable angina
- B. Unstable angina
- C. Acute myocardial infarction
- D. Prinzmetal's angina
Correct Answer: C
Rationale: The patient is most likely experiencing an acute myocardial infarction (MI) based on the presentation of crushing chest pain lasting longer than 20 minutes, diaphoresis, dyspnea, and ST-segment elevation on the ECG. These symptoms are consistent with the classic presentation of an ST-segment elevation myocardial infarction (STEMI), which is a type of acute MI that is characterized by prolonged ischemia leading to myocardial cell death. In this case, the ST-segment elevation in the anterior leads indicates myocardial damage in the corresponding area of the heart supplied by the affected coronary artery. This is a medical emergency that requires urgent intervention to restore blood flow to the affected myocardium and prevent further complications.
Nurse Gay is assigned in the Medical Unit. She is guided that in documentation, she should use abbreviation that is ______.
- A. used automatically to save precious time.
- B. reduced to the minimum in all units.
- C. approved standard list by the hospital.
- D. not used at all because it can be misinterpreted.
Correct Answer: C
Rationale: Nurse Gay should use abbreviations that are part of an approved standard list by the hospital. Using standardized abbreviations ensures clarity, accuracy, and consistency in documentation. It helps in preventing misinterpretation, errors, and ambiguity in patient records. By following an approved list of abbreviations, healthcare professionals can communicate effectively and efficiently while maintaining patient safety and quality of care.