Nokea
A client asks nurse Carlos the rationale for giving multi-drug treatment for tuberculosis. Which is an appropriate response?
- A. multiple drugs allow reduced levels of drugs to be given
- B. multiple drugs reduce undesirable drug side-effect
- C. multiple drugs potentiate the action fo the drugs
- D. multiple drugs reduce development of resistant strains of the bacteria
Correct Answer: D
Rationale: The correct answer is D because using multiple drugs for tuberculosis reduces the development of resistant strains of the bacteria. When multiple drugs are used simultaneously, it decreases the likelihood of the bacteria developing resistance to any single drug. This approach helps to ensure that the treatment remains effective over time.
Explanation for other choices:
A: While using multiple drugs may allow for reduced dosages, the primary rationale is not solely to administer lower levels of drugs.
B: Although using multiple drugs may help in managing side effects, the primary rationale is to prevent the development of resistant strains.
C: While multiple drugs may have a synergistic effect, the main purpose is to prevent resistance rather than potentiate the action of individual drugs.
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A 34 year old male client is diagnosed with encephalitis. Medication has been started for him and he is receiving nursing care. Which of the ff nursing interventions are the most critical for such a client? Choose all that apply
- A. Measuring fluid intake and output
- B. Evaluating the clients ventilation capacity and lung sound frequently
- C. Observing closely for signs of respiratory distress
- D. Administering an indwelling urethral catheter
Correct Answer: C
Rationale: The correct answer is C - Observing closely for signs of respiratory distress. In encephalitis, there is a risk of respiratory compromise due to brain inflammation affecting the respiratory center. Monitoring for signs of respiratory distress is critical to intervene promptly if breathing becomes compromised.
A - Measuring fluid intake and output is important but not as critical as monitoring respiratory distress in encephalitis.
B - Evaluating ventilation capacity and lung sounds is important, but close observation for respiratory distress takes precedence for immediate intervention.
D - Administering an indwelling urethral catheter is not directly related to the client's immediate critical needs in encephalitis.
Mr. RR is being prepared for surgery. Nursing care would include:
- A. Careful assessment of neurologic signs to establish baseline data for post-operative care
- B. Planning activities for Mr. RR
- C. Administration of an SS enema to prevent post-operative impaction
- D. Explaining to Mr. RR post-operative complications
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Assessment of neurologic signs establishes baseline for post-op care.
2. Helps detect any changes post-surgery.
3. Enables prompt intervention if any issues arise.
4. Planning activities (B) is not a priority pre-surgery.
5. Enema (C) may not be necessary for all surgeries.
6. Explaining complications (D) is important but not a primary pre-op nursing care.
The nurse evaluates a certified nursing assistant. Which of the following actions by the CAN demonstrates understanding of standard precautions?
- A. Wears gloves during all client contact
- B. Cleans blood spills with soap and water
- C. Pours bulk blood and other secretions down a drain connected to a sanitary sewer
- D. Carries blood sample to the lab in an open basket
Correct Answer: A
Rationale: The correct answer is A because wearing gloves during all client contact is a key practice in standard precautions to prevent the spread of infection. Gloves act as a barrier to protect both the healthcare worker and the patient from potential pathogens. Choice B is incorrect as cleaning blood spills with soap and water is not sufficient for infection control. Choice C is incorrect because pouring bulk blood and secretions down a drain is a violation of biohazard disposal protocols. Choice D is incorrect as carrying a blood sample in an open basket can lead to potential exposure to bloodborne pathogens.
The nurse is preparing to administer a unit of blood to a client’s who’s anemic. After its removal from the refrigerator, the blood should be administered within:
- A. 1 hour
- B. 4 hours
- C. 2 hours
- D. 6 hours
Correct Answer: C
Rationale: The correct answer is C: 2 hours. Blood should be administered within 30 minutes to 4 hours after removal from the refrigerator to prevent bacterial growth and maintain its efficacy. Option C falls within this timeframe, ensuring safety and effectiveness. Option A (1 hour) is too short, while option B (4 hours) and option D (6 hours) exceed the recommended timeframe, increasing the risk of bacterial contamination and compromising the quality of the blood product.
A client requires minor surgery for removal of a basal cell tumor. The anesthesiologist administers the anesthetic ketamine hydrochloride (Ketalar), 60g IV. After Ketamine administration, the nurse should monitor the client for:
- A. Muscle rigidity and spasms
- B. Hiccups
- C. Extrapyramidal reactions
- D. Respiratory depression
Correct Answer: A
Rationale: The correct answer is A: Muscle rigidity and spasms. Ketamine can cause muscle rigidity and spasms as a side effect, especially at higher doses. This is a known adverse reaction to Ketamine administration. Monitoring for muscle rigidity and spasms is important to ensure the safety of the client during and after surgery.
Incorrect choices:
B: Hiccups - Hiccups are not a common side effect of Ketamine administration.
C: Extrapyramidal reactions - Ketamine is not known to cause extrapyramidal reactions.
D: Respiratory depression - Ketamine typically does not cause respiratory depression, which is more commonly associated with other anesthetics like opioids.
Therefore, choice A is the correct answer as it aligns with the known side effects of Ketamine.