Nokea
A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is N R I G B.C M U S N T O based on which of the following?
- A. Hemorrhage is the primary concern.
- B. She will be unable to conceive in the future.
- C. Bed rest and analgesics are the recommended treatment.
- D. A D&C will be performed to remove the products of conception.
Correct Answer: A
Rationale: The correct answer is A because hemorrhage is the primary concern in ectopic pregnancy due to the risk of rupture and severe bleeding. Immediate intervention is crucial to prevent life-threatening complications.
Choice B is incorrect as future fertility may be affected but is not the immediate concern. Choice C is incorrect as bed rest and analgesics are not effective treatments for ectopic pregnancy. Choice D is incorrect as a D&C is not performed in ectopic pregnancy; surgical intervention is required to remove the ectopic pregnancy.
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A nurse provides care on a bone marrow transplant unit and is preparing a female patient for a hematopoietic stem cell transplantation (HSCT) the following day. What information should the nurse emphasize to the patients family and friends?
- A. Your family should likely gather at the bedside in case theres a negative outcome.
- B. Make sure she doesnt eat any food in the 24 hours before the procedure.
- C. Wear a hospital gown when you go into the patients room.
- D. Do not visit if youve had a recent infection.
Correct Answer: D
Rationale: The correct answer is D: Do not visit if you've had a recent infection. This is crucial to prevent the transmission of infections to the patient, who will have a compromised immune system post-HSCT. Family and friends with recent infections can pose a serious risk to the patient's health.
Choice A is incorrect because it instills fear and negativity in the family without providing any tangible benefits.
Choice B is incorrect as fasting is not typically required before a HSCT and can be harmful to the patient's nutritional status.
Choice C is incorrect as wearing a hospital gown is generally not necessary for visitors, unless specified by the healthcare team for infection control purposes.
A patient has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The patient has just exhibited seizure activity for the first time. What is the nurses priority response to this event?
- A. Identify the triggers that precipitated the seizure.
- B. Implement precautions to ensure the patients safety.
- C. Teach the patients family about the relationship between brain tumors and seizure activity.
- D. Ensure that the patient is housed in a private room.
Correct Answer: B
Rationale: The correct answer is B: Implement precautions to ensure the patient's safety. When a patient exhibits seizure activity for the first time, the immediate priority is to ensure the patient's safety by implementing precautions such as protecting the patient from injury during the seizure, ensuring a patent airway, and monitoring vital signs. Identifying triggers (Choice A) can be important for long-term management but is not the priority during an acute seizure. Teaching the family about the relationship between brain tumors and seizures (Choice C) can be done later but is not the immediate priority. Ensuring a private room (Choice D) is not the priority when the patient's safety during a seizure is the main concern.
A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage?
- A. Rinsing the ears with normal saline after swimming
- B. Avoiding loud environmental noises
- C. Instilling antibiotic ointments on a regular basis
- D. Avoiding the use of cotton swabs
Correct Answer: A
Rationale: The correct answer is A: Rinsing the ears with normal saline after swimming. This is because rinsing with normal saline helps to remove excess moisture and debris, preventing bacterial growth that can lead to otitis externa. Avoiding loud noises (B) is important for overall ear health but does not specifically prevent otitis externa. Instilling antibiotic ointments regularly (C) is not recommended as it can disrupt the ear's natural flora. Avoiding cotton swabs (D) is important to prevent injury but does not directly prevent otitis externa.
A nurse is using core measures to reduce healthdisparities. Which group should the nurse focus on to cause themost improvement in core measures?
- A. Caucasians
- B. Poor people
- C. Alaska Natives
- D. American Indians
Correct Answer: B
Rationale: The correct answer is B: Poor people. Focusing on poor people is likely to cause the most improvement in core measures because individuals living in poverty often face multiple barriers to accessing healthcare and have higher rates of chronic conditions. By targeting this group, the nurse can address social determinants of health, improve healthcare access, and address disparities in healthcare outcomes. Other choices (A, C, D) are not as impactful as poverty is a significant factor influencing health disparities.
A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing patient teaching prior to the patients discharge. In the event of an anaphylactic reaction, the nurse informs the patient that she should self-administer epinephrine in what site?
- A. Forearm
- B. Thigh
- C. Deltoid muscle
- D. Abdomen
Correct Answer: B
Rationale: The correct answer is B: Thigh. When administering epinephrine during an anaphylactic reaction, the thigh is the recommended site due to its large muscle mass and quick absorption rate. Steps: 1. Remove safety cap. 2. Firmly push the auto-injector against the thigh until it clicks. 3. Hold in place for a few seconds. 4. Seek medical help immediately. Rationale for incorrect choices: A: Forearm - Not recommended due to smaller muscle mass and slower absorption. C: Deltoid muscle - Not preferred as it may not provide as rapid absorption as the thigh. D: Abdomen - Not ideal due to potential fat layers that could affect absorption speed.