Nokea
A client has possible malignancy of the colon, and surgery is scheduled. The rationale for administering Neomycin preoperatively is to:
- A. Prevent infection postoperatively
- B. Eliminate the need for preoperative enemas
- C. Decreased and retard the growth of normal bacteria in the intestines
- D. Treat cancer of the colon
Correct Answer: C
Rationale: The correct answer is C because Neomycin is given preoperatively to decrease and retard the growth of normal bacteria in the intestines. This helps reduce the risk of infection during surgery by minimizing the number of bacteria present in the colon. Options A, B, and D are incorrect because Neomycin is not given to prevent infection postoperatively, eliminate the need for preoperative enemas, or treat cancer of the colon. The main purpose of administering Neomycin in this scenario is to create a sterile surgical field by reducing the normal flora in the intestines.
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A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?
- A. “A man should wear a latex condom during intimate sexual contact.”
- B. “I’ve heard about people who got AIDS from blood transfusions.”
- C. “I won’t donate blood because I don’t want to get AIDS.”
- D. “IV drug users can get HIV from sharing needles.”
Correct Answer: C
Rationale: The correct answer is C. This statement warrants clarification as donating blood does not put individuals at risk of getting HIV. Blood donation involves a sterile process that ensures safety. Choice A is correct as using condoms can help prevent the transmission of HIV. Choice B is incorrect because modern blood screening techniques have greatly reduced the risk of HIV transmission through blood transfusions. Choice D is also correct as sharing needles is a high-risk behavior for HIV transmission. In summary, only choice C is incorrect as donating blood does not pose a risk of acquiring HIV.
A nurse is conducting a nursing health history. Which component will the nurse address?
- A. Nurse’s concerns
- B. Patient expectations
- C. Current treatment orders
- D. Nurse’s goals for the patient
Correct Answer: B
Rationale: The correct answer is B: Patient expectations. During a nursing health history, the nurse focuses on gathering information about the patient's health concerns, medical history, lifestyle, and expectations for their care. Addressing patient expectations is crucial for providing patient-centered care and establishing a therapeutic relationship. The other choices are incorrect because:
A: Nurse's concerns are not the primary focus of a nursing health history.
C: Current treatment orders are important but are typically addressed during a physical assessment or when implementing care.
D: Nurse's goals for the patient are important but should be developed in collaboration with the patient based on their needs and preferences.
A client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis?
- A. Stool hematest
- B. Abdominal computed tomography (CT)
- C. Carcinoembryonic antigen (CEA) scan
- D. Sigmoidoscopy
Correct Answer: D
Rationale: The correct answer is D: Sigmoidoscopy. This procedure allows direct visualization of the lower colon and rectum, enabling the detection of colorectal cancer. Stool hematest (A) detects blood in the stool but does not confirm cancer. Abdominal CT (B) can show abnormalities but is not specific for colorectal cancer. CEA scan (C) measures a tumor marker but is not definitive for diagnosis. Sigmoidoscopy (D) is the gold standard for diagnosing colorectal cancer as it allows for direct visualization and tissue biopsy.
A client receiving ferrous sulfate (Fer-Iron) therapy to treat an iron deficiency reports taking an antacid frequently to relieve heart burn. Which nursing instruction should the nurse provide?
- A. “Take ferrous sulfate and the antacid together.”
- B. “Take ferrous sulfate and the antacid at least 2 hours apart.”
- C. “Avoid taking an antacid altogether.”
- D. “Take ferrous sulfate and the antacid at least 1 hour apart.”
Correct Answer: B
Rationale: The correct answer is B: "Take ferrous sulfate and the antacid at least 2 hours apart."
Rationale:
1. Iron absorption is decreased in the presence of antacids due to decreased gastric acidity.
2. Antacids can bind to iron and reduce its absorption.
3. Taking them 2 hours apart allows for optimal iron absorption without interference from the antacid.
4. Taking them together (choice A) would decrease iron absorption.
5. Avoiding antacids altogether (choice C) may not be necessary if spaced apart appropriately.
6. Taking them 1 hour apart (choice D) may still lead to decreased iron absorption due to antacid interference.
Which of the ff. problems during the immediate postoperative course ff. lumbar microdiskectomy should be reported to the physician immediately?
- A. Incisional pain
- B. Inability to move affected leg
- C. Two-inch area of bleeding on dressing
- D. Muscle spasm of affected
Correct Answer: B
Rationale: The correct answer is B because the inability to move the affected leg post lumbar microdiskectomy could indicate a serious complication like nerve damage or blood clot. This would require immediate medical attention to prevent further complications. Incisional pain (A) is common and can be managed with pain medication. A two-inch area of bleeding on the dressing (C) is concerning but can be managed with proper wound care unless it is excessive. Muscle spasm (D) is also common postoperatively and can be managed with medications or physical therapy.