Nokea
A client has just been diagnosed with active tuberculosis. Which of the following nursing interventions should the nurse perform to prevent transmission to others?
- A. Begin drug therapy within 72 hours of diagnosis
- B. Place the client in a positive-pressure room
- C. Initiate standard precautions
- D. Place the client in a negative-pressure room
Correct Answer: D
Rationale: A client diagnosed with active tuberculosis should be placed in isolation in a negative-pressure room to prevent transmission of infection to others. Placing the client in a negative-pressure room ensures that air is exhausted to the outside and received from surrounding areas, preventing tuberculin particles from traveling through the ventilation system and infecting others. Initiating standard precautions, as mentioned in choice C, is essential for infection control but is not specific to preventing transmission in the case of tuberculosis. Beginning drug therapy within 72 hours of diagnosis, as in choice A, is crucial for the treatment of tuberculosis but does not directly address preventing transmission. Placing the client in a positive-pressure room, as in choice B, is incorrect as positive-pressure rooms are used for clients with compromised immune systems to prevent outside pathogens from entering the room, which is not suitable for a client with active tuberculosis.
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A newborn infant in the nursery has developed vomiting, poor feeding, lethargy, and respiratory distress, and has been diagnosed with necrotizing enterocolitis. Which of the following nursing interventions is most appropriate for this infant?
- A. Feed the infant 30 cc of sterile water
- B. Position the infant on his back
- C. Administer antibiotics as ordered
- D. Allow the infant to breastfeed
Correct Answer: C
Rationale: Necrotizing enterocolitis (NEC) is a serious condition characterized by ischemic bowel, leading to gastrointestinal symptoms, lethargy, poor feeding, and respiratory distress. In the management of NEC, it is crucial to stop oral feedings, insert a nasogastric tube for decompression, and administer antibiotics as prescribed by the physician. Therefore, the most appropriate nursing intervention for an infant with NEC is to administer antibiotics as ordered.
Choice A, feeding the infant sterile water, is incorrect because oral feedings should be stopped in NEC. Choice B, positioning the infant on his back, is not directly related to the treatment of NEC. Choice D, allowing the infant to breastfeed, is contraindicated in NEC as oral feedings should be ceased to prevent further complications.
A 30-year-old woman is experiencing anaphylaxis from a bee sting. Emergency personnel have been called. The nurse notes the woman is breathing but short of breath. Which of the following interventions should the nurse do first?
- A. Initiate cardiopulmonary resuscitation
- B. Check for a pulse
- C. Ask the woman if she carries an emergency medical kit
- D. Stay with the woman until help comes
Correct Answer: C
Rationale: In a situation where a patient is experiencing anaphylaxis, it is crucial to act swiftly. Asking the woman if she carries an emergency medical kit is the most appropriate initial intervention. Many individuals with a history of anaphylaxis carry epinephrine auto-injectors, such as epi-pens, which can be life-saving in such situations. Initiating cardiopulmonary resuscitation (CPR) is not indicated as the patient is breathing but short of breath, and CPR is not the first-line intervention for anaphylaxis. Checking for a pulse, though important, is not the initial priority in managing anaphylaxis. Staying with the woman until help arrives is essential for providing support and monitoring her condition, but confirming the availability of an emergency medical kit takes precedence to promptly address the anaphylactic reaction.
A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time caretaker. The nurse is most concerned about which side effect of heparin?
- A. Back Pain
- B. Fever and Chills
- C. Risk for Bleeding
- D. Dizziness
Correct Answer: C
Rationale: The correct answer is 'Risk for Bleeding.' A patient with dementia may have impaired judgment and may be prone to falls or injuries, increasing the risk of bleeding while on heparin therapy. Monitoring for signs of bleeding is crucial in this situation. Choice A, 'Back Pain,' is not a common side effect of heparin. Choice B, 'Fever and Chills,' is not a typical side effect of heparin but may indicate other underlying conditions. Choice D, 'Dizziness,' is not a common side effect of heparin and is not the primary concern in this scenario.
A patient with severe Gastroesophageal Reflux Disease is receiving discharge teaching. Which of these statements by the patient indicates a need for more teaching?
- A. ''I'm going to limit my meals to 2-3 per day to reduce acid secretion.''
- B. ''I'm going to make sure to remain upright after meals and elevate my head when I sleep.''
- C. ''I won't be drinking tea or coffee or eating chocolate anymore.''
- D. ''I'm going to start trying to lose some weight.''
Correct Answer: A
Rationale: The correct answer is ''I'm going to limit my meals to 2-3 per day to reduce acid secretion.'' This statement indicates a need for more teaching because large meals increase the volume and pressure in the stomach, delaying gastric emptying, and worsening symptoms of Gastroesophageal Reflux Disease (GERD). The recommended approach is to eat smaller, more frequent meals (4-6 small meals a day) to reduce acid reflux. Choices B, C, and D demonstrate good understanding of GERD management by highlighting the importance of staying upright after meals, avoiding trigger foods like tea, coffee, and chocolate, and addressing weight management, which are all appropriate strategies to manage GERD symptoms.
A 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective?
- A. Bowel sounds are present.
- B. Grey Turner sign resolves.
- C. Electrolyte levels are normal.
- D. Abdominal pain is decreased.
Correct Answer: D
Rationale: The correct answer is 'Abdominal pain is decreased.' In a patient with acute pancreatitis, the goal of using an NG tube for suction and keeping the patient NPO is to decrease the release of pancreatic enzymes and alleviate pain. Therefore, a decrease in abdominal pain would indicate the effectiveness of these therapies. Bowel sounds being present do not necessarily indicate treatment effectiveness, as they can still be present even if the therapies are not fully effective. Normal electrolyte levels are important but do not directly reflect the efficacy of NG suction and NPO status. The resolution of Grey Turner sign, a bruising over the flanks associated with pancreatitis, is a late and non-specific finding and waiting for it to resolve is not a reliable indicator of treatment effectiveness.