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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 is aware of the need to assess patients risks for anaphylaxis. What health care procedure constitutes the highest risk for anaphylaxis?
- A. Administration of the measles-mumps-rubella (MMR) vaccine
- B. Rapid administration of intravenous fluids
- C. Computed tomography with contrast solution
- D. Administration of nebulized bronchodilators
Correct Answer: C
Rationale: The correct answer is C: Computed tomography with contrast solution. This procedure involves the use of contrast agents that can trigger anaphylaxis due to the patient's allergic reaction to the contrast solution. Contrast solutions contain substances like iodine, which can cause severe allergic reactions in some individuals. Anaphylaxis is a life-threatening allergic reaction that can occur rapidly and requires immediate intervention. Assessing the risk for anaphylaxis during this procedure is crucial to prevent any potential harm to the patient.
Incorrect choices:
A: Administration of the measles-mumps-rubella (MMR) vaccine - While allergic reactions can occur with vaccines, the risk of anaphylaxis with MMR vaccine is lower compared to the contrast solution used in CT scans.
B: Rapid administration of intravenous fluids - Rapid IV fluid administration can cause fluid overload or electrolyte imbalances, but it is not typically associated with triggering anaphylaxis.
D: Administration of nebulized bronchodil
A woman aged 48 years comes to the clinic because she has discovered a lump in her breast. After diagnostic testing, the woman receives a diagnosis of breast cancer. The woman asks the nurse when her teenage daughters should begin mammography. What is the nurses best advice?
- A. Age 28
- B. Age 35
- C. Age 38
- D. Age 48
Correct Answer: D
Rationale: The correct answer is D: Age 48. This recommendation aligns with the current guidelines from major health organizations, such as the American Cancer Society, which suggest that women at average risk should start regular mammograms at age 45 to 54. Screening before age 45 may lead to unnecessary procedures due to false positives. Beginning at age 48 allows for early detection without subjecting the daughters to unnecessary testing at a younger age. Choices A, B, and C are incorrect as they suggest starting mammography at younger ages than recommended, which can increase the likelihood of false positives and unnecessary interventions.
A patient has herpes simplex 2 viral infection (HSV2). The nurse recognizes that which of the following should be included in teaching the patient?
- A. The virus causes cold sores of the lips.
- B. The virus may be cured with antibiotics.
- C. The virus, when active, may not be contracted during intercourse.
- D. Treatment is aimed at relieving symptoms.
Correct Answer: D
Rationale: The correct answer is D because treatment for HSV2 focuses on relieving symptoms since the virus cannot be cured. Antiviral medications can help manage outbreaks and reduce the frequency and severity of symptoms. Option A is incorrect as HSV2 typically presents as genital herpes, not cold sores on the lips (usually caused by HSV1). Option B is incorrect since antibiotics are ineffective against viruses. Option C is incorrect as HSV2 is most contagious during active outbreaks, making it important to practice safe sex to prevent transmission.
A patient has been admitted to the hospital numerous times. The nurse asks the patient to share a personal story about the care that has been received. Which interaction is the nurse using?
- A. Nonjudgmental
- B. Socializing
- C. Narrative
- D. SBAR
Correct Answer: C
Rationale: The correct answer is C: Narrative. The nurse is using a narrative interaction by asking the patient to share a personal story. This helps the patient express their experiences, emotions, and perspectives, promoting a deeper understanding of their care needs. A: Nonjudgmental is incorrect as it focuses on avoiding biases. B: Socializing is incorrect as it implies casual conversation. D: SBAR is incorrect as it stands for Situation, Background, Assessment, and Recommendation, used for concise communication in healthcare settings.
A nurse is providing care to a group of patients.Which patient will the nurse seefirst?
- A. A child about to receive a normal saline enema
- B. A teenager about to receive loperamide for diarrhea
- C. An older patient with glaucoma about to receive an enema
- D. A middle-aged patient with myocardial infarction about to receive docusate sodium
Correct Answer: C
Rationale: The correct answer is C because an older patient with glaucoma is at risk for increased intraocular pressure when receiving an enema. This situation requires immediate attention to prevent potential complications like vision loss. The other choices do not pose immediate risks that require urgent intervention. A and B can wait for a brief period, while D is not time-sensitive in the context of a myocardial infarction. The priority is always given to the patient with the highest risk of harm if the intervention is delayed.