Nokea
A junior nursing student is having an observation day in the operating room. Early in the day, the student tells the OR nurse that her eyes are swelling and she is having trouble breathing. What should the nurse suspect?
- A. Cytotoxic reaction due to contact with the powder in the gloves
- B. Immune complex reaction due to contact with anesthetic gases
- C. Anaphylaxis due to a latex allergy
- D. Delayed reaction due to exposure to cleaning products
Correct Answer: C
Rationale: The correct answer is C: Anaphylaxis due to a latex allergy. Anaphylaxis is a severe allergic reaction that can be triggered by exposure to latex products such as gloves in the operating room. The symptoms of swelling of the eyes and difficulty breathing are classic signs of anaphylaxis.
Rationale:
1. Swelling of the eyes and difficulty breathing are hallmark symptoms of anaphylaxis.
2. Latex is a common allergen that can cause severe allergic reactions like anaphylaxis.
3. The student's symptoms are occurring shortly after entering the operating room, suggesting an acute allergic reaction.
4. The other choices (A, B, D) do not align with the symptoms presented and are less likely in this scenario.
You may also like to solve these questions
A nurse is a member of an interdisciplinary teamthat uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do?
- A. Add this data to the problem list.
- B. Focus chart using the DAR format.
- C. Document the variance in the patient’s record.
- D. Report a positive variance in the next interdisciplinary team meeting.
Correct Answer: C
Rationale: The correct answer is C: Document the variance in the patient’s record. By documenting the variance in the patient's record, the nurse can provide a clear record of the deviation from the critical pathway. This documentation is essential for tracking the patient's progress accurately and identifying potential issues that may require intervention. It allows for proper communication among the interdisciplinary team and ensures that everyone is aware of the deviation.
Choice A is incorrect because adding data to the problem list may not provide a comprehensive record of the variance. Choice B is incorrect because focusing on charting using the DAR format does not address the deviation from the critical pathway. Choice D is incorrect because reporting a positive variance in the next team meeting may not accurately reflect the patient's actual progress and may lead to miscommunication within the team.
A nurse is preparing a patient for allergy skin testing. Which of the following precautionary steps is most important for the nurse to follow?
- A. The patient must not have received an immunization within 7 days.
- B. The nurse should administer albuterol 30 to 45 minutes prior to the test.
- C. Prophylactic epinephrine should be administered before the test.
- D. Emergency equipment should be readily available.
Correct Answer: D
Rationale: The correct answer is D. Having emergency equipment readily available is crucial during allergy skin testing as it can lead to severe allergic reactions. This precaution ensures prompt intervention in case of anaphylaxis. Other choices are incorrect because: A) Recent immunizations do not directly impact the skin testing process. B) Administering albuterol is not a standard pre-test requirement. C) Prophylactic epinephrine is not routinely given before allergy skin testing.
When administering a patients eye drops, the nurse recognizes the need to prevent absorption by the nasolacrimal duct. How can the nurse best achieve this goal?
- A. Ensure that the patient is well hydrated at all times.
- B. Encourage self-administration of eye drops.
- C. Occlude the puncta after applying the medication.
- D. Position the patient supine before administering eye drops.
Correct Answer: C
Rationale: The correct answer is C: Occlude the puncta after applying the medication. By occluding the puncta after applying the eye drops, the nurse can prevent the medication from draining into the nasolacrimal duct and being absorbed systemically. This is important to ensure that the medication remains in the eye and exerts its intended local effect.
Choice A (Ensure that the patient is well hydrated at all times) is incorrect because hydration status does not directly prevent absorption through the nasolacrimal duct.
Choice B (Encourage self-administration of eye drops) is incorrect as the method of administration does not prevent absorption through the nasolacrimal duct.
Choice D (Position the patient supine before administering eye drops) is incorrect as it does not address the specific issue of preventing absorption through the nasolacrimal duct.
Which finding in the assessment of a patient following an abruption placenta could indicate a major complication?
- A. Urine output of 30 mL in 1 hour
- B. Blood pressure of 110/60 mm Hg
- C. Bleeding at IV insertion site
- D. Respiratory rate of 16 breaths per minute
Correct Answer: C
Rationale: The correct answer is C - bleeding at IV insertion site. This finding could indicate a major complication following an abruption placenta, such as disseminated intravascular coagulation (DIC) or hypovolemic shock. Bleeding at the IV site suggests a systemic issue affecting the patient's coagulation status. Choices A, B, and D are not directly indicative of a major complication following an abruption placenta. Urine output, blood pressure, and respiratory rate are important parameters to monitor but do not specifically point to a major complication in this context.
A patient newly diagnosed with breast cancer states that her physician suspects regional lymph node involvement and told her that there are signs of metastatic disease. The nurse learns that the patient has been diagnosed with stage IV breast cancer. What is an implication of this diagnosis?
- A. The patient is not a surgical candidate.
- B. The patients breast cancer is considered highly treatable.
- C. There is a 10% chance that the patients cancer will self-resolve.
- D. The patient has a 15% chance of 5-year survival.
Correct Answer: A
Rationale: Rationale for Correct Answer A: Stage IV breast cancer indicates distant metastasis, making the patient ineligible for curative surgery. Treatment for stage IV focuses on palliative care to manage symptoms and improve quality of life.
Summary of Other Choices:
B: Stage IV breast cancer is not considered highly treatable as it has spread beyond the breast and nearby lymph nodes, making it more challenging to cure.
C: There is no evidence to suggest that stage IV breast cancer will self-resolve. The prognosis for metastatic breast cancer is typically poor.
D: The 5-year survival rate for stage IV breast cancer is generally lower than 15%, making this choice incorrect.