Nokea
A blood-soaked peripad weighs 900 g. The nurse would document a blood loss of _____ mL.
- A. 1800
- B. 450
- C. 900
- D. 90
Correct Answer: C
Rationale: The correct answer is C (900 mL) because the weight of 900 g corresponds to a blood loss of the same amount in milliliters. Blood density is close to that of water, so 1 g ≈ 1 mL. Therefore, a blood-soaked peripad weighing 900 g indicates a blood loss of 900 mL. Choice A (1800 mL) is incorrect as it doubles the weight instead of converting it to milliliters. Choice B (450 mL) is incorrect as it halves the weight. Choice D (90 mL) is incorrect as it divides the weight by 10, which is too small for the blood loss indicated.
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A high-risk labor patient progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via cesarean birth. Which finding in the immediate postoperative period indicates that the patient is at risk of developing HELLP syndrome?
- A. Platelet count of 50,000/mcL
- B. Liver enzyme levels within normal range
- C. Negative for edema
- D. No evidence of nausea or vomiting
Correct Answer: A
Rationale: The correct answer is A: Platelet count of 50,000/mcL. HELLP syndrome is a severe form of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelet count. In this scenario, a platelet count of 50,000/mcL indicates thrombocytopenia, which is a key component of HELLP syndrome. Low platelet count can lead to bleeding complications and is a critical indicator of the syndrome.
Choices B, C, and D are incorrect.
B: Liver enzyme levels within normal range do not necessarily indicate the presence of HELLP syndrome, as elevated liver enzymes are a hallmark feature of the syndrome.
C: Being negative for edema is not a reliable indicator of HELLP syndrome, as edema is a common finding in preeclampsia but not specific to HELLP syndrome.
D: No evidence of nausea or vomiting is not a specific sign of HELLP syndrome, as these
The nurse is caring for a patient diagnosed with Parkinsons disease. The patient is having increasing problems with rising from the sitting to the standing position. What should the nurse suggest to the patient to use that will aid in getting from the sitting to the standing position as well as aid in improving bowel elimination?
- A. Use of a bedpan
- B. Use of a raised toilet seat
- C. Sitting quietly on the toilet every 2 hours
- D. Following the outlined bowel program
Correct Answer: B
Rationale: Correct Answer: B - Use of a raised toilet seat
Rationale: A raised toilet seat helps the patient with Parkinson's disease by providing additional height, making it easier for them to transition from sitting to standing. This aids in improving mobility and reducing the risk of falls. Furthermore, the raised seat can also promote proper positioning for bowel elimination, making the process more comfortable and effective.
Incorrect Choices:
A: Using a bedpan does not address the issue of transitioning from sitting to standing, nor does it aid in improving bowel elimination for the patient.
C: Sitting quietly on the toilet every 2 hours may not directly address the physical challenges the patient is facing in transitioning from sitting to standing.
D: Following the outlined bowel program is important, but it does not specifically address the physical support needed to transition from sitting to standing for a patient with Parkinson's disease.
Which piece of data will the nurse use for “B” when using SBAR?
- A. Having chest pain
- B. Pulse rate of 108
- C. History of angina
- D. Oxygen is needed
Correct Answer: C
Rationale: The nurse will use the history of angina for "B" when using SBAR because it provides relevant background information about the patient's cardiac condition. This helps the nurse understand the context of the current situation and make appropriate decisions. Pulse rate of 108 (choice B) is a specific vital sign and not an appropriate choice for "B" in SBAR. Having chest pain (choice A) is important but does not provide the necessary background information like the history of angina does. Oxygen being needed (choice D) is a current intervention and not relevant for "B" in SBAR, which focuses on providing background information.
A patient who is receiving care for osteosarcoma has been experiencing severe pain since being diagnosed. As a result, the patient has been receiving analgesics on both a scheduled and PRN basis. For the past several hours, however, the patients level of consciousness has declined and she is now unresponsive. How should the patients pain control regimen be affected?
- A. The patients pain control regimen should be continued.
- B. The pain control regimen should be placed on hold until the patients level of consciousness improves.
- C. IV analgesics should be withheld and replaced with transdermal analgesics.
- D. The patients analgesic dosages should be reduced by approximately one half. Chapter 36: Immune : HIV/AIDS: stages, testing, complications, assessment; care & Safe Sexual practices
Correct Answer: C
Rationale: The correct answer is C. When a patient's level of consciousness declines and becomes unresponsive, it may indicate a potential overdose of analgesics. To ensure patient safety, IV analgesics should be withheld and replaced with transdermal analgesics, which provide a more controlled and gradual release of medication. This switch helps prevent further overdose and adverse effects. Continuing the current pain control regimen (Choice A) may worsen the situation. Placing the pain control regimen on hold (Choice B) may lead to inadequate pain management. Reducing analgesic dosages (Choice D) may not be sufficient in addressing the overdose issue.
A patients decline in respiratory and renal function has been attributed to Goodpasture syndrome, which is a type II hypersensitivity reaction. What pathologic process underlies the patients health problem?
- A. Antigens have bound to antibodies and formed inappropriate immune complexes.
- B. The patients body has mistakenly identified a normal constituent of the body as foreign.
- C. Sensitized T cells have caused cell and tissue damage.
- D. Mast cells have released histamines that directly cause cell lysis.
Correct Answer: B
Rationale: The correct answer is B because in Goodpasture syndrome, the patient's immune system mistakenly targets normal constituents of the body, specifically the basement membrane of the kidneys and lungs. This autoimmune response leads to inflammation and damage in these organs, resulting in respiratory and renal dysfunction.
Choice A is incorrect as immune complexes are not the primary mechanism in Goodpasture syndrome. Choice C is incorrect as it refers to T cell-mediated immune responses, which are not the main drivers in this condition. Choice D is incorrect as histamine release and cell lysis are not the main processes involved in Goodpasture syndrome.