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A client with tuberculosis (TB) is taking isoniazid (INH). Which instruction is most important for the nurse to include?
- A. Take the medication with food to avoid stomach upset.
- B. Avoid exposure to sunlight while taking this medication.
- C. Report any numbness or tingling in extremities.
- D. Have liver function tests done regularly.
Correct Answer: D
Rationale: Step 1: Isoniazid (INH) can cause liver toxicity.
Step 2: Regular liver function tests help monitor for liver damage.
Step 3: Monitoring liver function is crucial to prevent serious complications.
Step 4: Other choices are not directly related to INH's side effects.
Summary: Choice D is correct as it directly addresses a potential serious side effect of INH. Choices A, B, and C are not directly relevant to the medication's side effects.
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A patient who had major surgery is experiencing emotional stress as well as physiologic stress from the effects of surgery. What can this stress cause?
- A. Diuresis
- B. Hyperkalemia
- C. Fluid retention
- D. Impaired blood coagulation
Correct Answer: C
Rationale: Surgical stress triggers hormonal responses leading to fluid retention.
A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (SATA)
- A. Age
- B. Hypertension
- C. Obesity
- D. Smoking
Correct Answer: B
Rationale: Step-by-step rationale:
1. Hypertension is a modifiable risk factor as it can be controlled through lifestyle changes and medication.
2. Age is a non-modifiable risk factor, as it naturally increases the risk of coronary artery disease.
3. Obesity is a modifiable risk factor, as weight management through diet and exercise can reduce the risk.
4. Smoking is a modifiable risk factor, as quitting smoking can significantly reduce the risk.
Summary:
B is correct as it is a modifiable risk factor that can be actively managed. A, C, and D are incorrect as age is non-modifiable and obesity and smoking are modifiable but were not selected as correct options.
A client with heart failure has gained 2 kg (4.4 lbs) in the past 24 hours. What action should the nurse take first?
- A. Restrict the client's fluid intake.
- B. Assess the client's respiratory status.
- C. Administer diuretics as ordered.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: The correct answer is B: Assess the client's respiratory status. The first action should be to assess the client's respiratory status as the weight gain could indicate fluid retention leading to pulmonary congestion, a common complication in heart failure. By assessing the respiratory status, the nurse can determine if there are signs of respiratory distress such as increased work of breathing, crackles, or shortness of breath. This assessment will help in identifying any immediate need for interventions such as oxygen therapy or diuretics. Restricting fluid intake (choice A) is important but not the first step. Administering diuretics (choice C) should be based on assessment findings. Notifying the healthcare provider (choice D) can be done after assessing the client's respiratory status.
A client is moving to a new state and needs to find a new doctor and hospital there. What advice by the nurse is best?
- A. Ask the hospitals there about standard nurse-client ratios.
- B. Choose the hospital that has the newest technology.
- C. Find a hospital that is accredited by The Joint Commission.
- D. Use a facility affiliated with a medical or nursing school.
Correct Answer: C
Rationale: The correct answer is C: Find a hospital that is accredited by The Joint Commission. This is the best advice because The Joint Commission accreditation ensures that the hospital meets high-quality standards in patient care, safety, and performance. Accreditation indicates the hospital's commitment to providing excellent healthcare services.
A: Asking about nurse-client ratios is important for patient safety, but it is not the most critical factor when choosing a hospital.
B: Choosing a hospital based solely on technology does not guarantee quality care or safety.
D: Using a facility affiliated with a medical or nursing school may provide access to cutting-edge research and expertise, but it does not guarantee overall quality of care provided by the hospital.
During a shower three days ago, Jeremy Robb, 19, discovered a firm lump in his left testis. He went to the student health center at his university, was referred to a local physician and was admitted to the hospital for a left orchiectomy and lymph node resection. Risk factors for cancer of the testes include:
- A. smoking.
- B. undescended testicle.
- C. multiple sex partners.
- D. genital trauma.
Correct Answer: B
Rationale: Smoking has been linked to cancer of the lungs, bladder, and pancreas, but has not been linked directly to cancer of the testes. Males who had undescended testicle(s) have been found to have a higher incidence of cancer of the testes later. It is theorized that the internal heat the testes are exposed to while in the abdomen causes the damage to the testes. Multiple sex partners is a risk for genital warts, AIDS, and sexually transmitted diseases, but has not been shown to be a risk for cancer of the testes. Genital trauma more likely causes bladder and ureteral damage.