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A client has had heavy menstrual bleeding for 6 months. Her gynecologist diagnoses microcytic hypochromic anemia and prescribes ferrous sulfate (Feosol), 300mg PO daily. Before initiating iron therapy, the nurse reviews the client’s medical history. Which condition would contraindicate the use of ferrous sulfate?
- A. Pregnancy
- B. Ulcerative colitis
- C. Asthma
- D. Severely impaired liver function
Correct Answer: B
Rationale: The correct answer is B: Ulcerative colitis. Iron therapy can exacerbate gastrointestinal issues, including ulcerative colitis due to its potential to cause irritation and inflammation in the digestive tract. This can lead to worsening symptoms and complications for the client.
A: Pregnancy is not a contraindication for iron therapy; in fact, it is commonly prescribed during pregnancy to prevent or treat anemia.
C: Asthma is not a contraindication for iron therapy as it does not directly interact with asthma or its treatment.
D: Severely impaired liver function is not a direct contraindication for iron therapy, although caution may be needed in such cases due to iron metabolism being affected by liver function.
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When the patient’s signature is witnessed by the nurse on the surgical consent, which of the following does the nurse’s signature indicate?
- A. The nurse obtained informed consent.
- B. The nurse provided informed consent.
- C. The nurse answered all surgical procedure questions.
- D. The nurse verified that the patient signed the consent.
Correct Answer: D
Rationale: The correct answer is D because the nurse's signature indicates that they verified the patient's signature on the consent form. This step ensures that the patient has signed the document willingly. Choice A is incorrect because the nurse doesn't obtain informed consent, that's the responsibility of the physician. Choice B is incorrect because nurses do not provide informed consent. Choice C is incorrect as the nurse witnessing the signature doesn't imply they answered all surgical procedure questions.
A brain abscess is a collection of pus within the substance of the brain and is caused by:
- A. Direct invasion of the brain
- B. Spread of infection by other organs
- C. Spread infection from nearby sites
- D. All of the above mechanisms
Correct Answer: D
Rationale: The correct answer is D because a brain abscess can be caused by direct invasion of the brain, spread of infection by other organs, and spread of infection from nearby sites. Direct invasion can occur from trauma or surgery, while infections from other organs like the lungs or heart can travel through the bloodstream to the brain. Infections from nearby sites such as the sinuses or ears can also spread to the brain. Therefore, all of these mechanisms can lead to the formation of a brain abscess. Choices A, B, and C alone do not encompass all the possible causes of a brain abscess, making D the correct comprehensive answer.
To treat cervical cancer, a client has had an applicator of radioactive material placed in the vagina. Which observation by the nurse indicates a radiation hazard?
- A. The client is maintained on strict bed rest
- B. The head of the bed is at 30-degree angle
- C. The client receives a complete bed bath each morning
- D. The nurse checks the applicator’s position every 4 hours
Correct Answer: B
Rationale: The correct answer is B because maintaining the head of the bed at a 30-degree angle can cause the radioactive material to shift within the client's body, increasing the risk of radiation exposure. This position should be avoided to prevent displacement of the applicator.
A: Strict bed rest is appropriate to minimize movement and dislodgement of the applicator, ensuring proper treatment delivery.
C: Providing a bed bath does not pose a radiation hazard as long as proper precautions are taken.
D: Checking the applicator's position every 4 hours is essential for monitoring and ensuring it remains in place to deliver the intended treatment.
A client with serum glucose level of 618mg/dl is admitted to the facility. He’s awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6F (38.1C), heart rate of 116 beats/min, and blood pressure of 108/70mHg. Based on these assessment findings, which nursing diagnosis take highest priority?
- A. Deficient volume related to osmotic diuresis
- B. Decreased cardiac output related to elevated heart rate
- C. Imbalanced nutrition: Less than body requirements related to insulin deficiency
- D. Ineffective thermoregulation related to dehydration
Correct Answer: D
Rationale: The correct answer is D, "Ineffective thermoregulation related to dehydration." The client's high serum glucose level of 618mg/dl indicates severe hyperglycemia, leading to dehydration. The client's hot, dry skin and elevated temperature can be signs of dehydration, impacting the body's ability to regulate temperature. Dehydration can also affect other vital signs, contributing to the elevated heart rate and low blood pressure. Addressing ineffective thermoregulation is crucial as it can lead to further complications.
Choices A, B, and C are not the highest priority because addressing dehydration and ineffective thermoregulation takes precedence due to the immediate risk of complications such as heatstroke or hypothermia. Deficient volume, decreased cardiac output, and imbalanced nutrition are important but not as urgent in this scenario.
A baby is born temporarily immune to the diseases to which the mother is immune. The nurse understands that this is an example of which of the following types of immunity?
- A. Naturally acquired passive immunity
- B. Naturally acquired active immunity
- C. Artificially acquired passive immunity
- D. Artificially acquired active immunity
Correct Answer: A
Rationale: The correct answer is A: Naturally acquired passive immunity. This type of immunity occurs when antibodies are passed from mother to baby through the placenta or breast milk, providing temporary protection. The baby does not produce its antibodies, hence it is passive. Choice B, naturally acquired active immunity, involves the body producing its antibodies after exposure to a pathogen. Choice C, artificially acquired passive immunity, involves receiving preformed antibodies from an external source. Choice D, artificially acquired active immunity, involves the body producing antibodies in response to vaccination.