Nokea
A nurse is caring for a client with a newly inserted pacemaker. What is the most important nursing action post-procedure?
- A. Monitor the insertion site for signs of infection.
- B. Educate the client about activity restrictions.
- C. Monitor the client's heart rate and rhythm.
- D. Assess the client's lung sounds for signs of fluid overload.
Correct Answer: A
Rationale: Post-procedure, monitoring the insertion site for signs of infection is crucial because it helps in early detection of any potential complications such as infection. While educating the client about activity restrictions, monitoring the client's heart rate and rhythm, and assessing lung sounds for signs of fluid overload are important aspects of care, the immediate priority post-procedure is to prevent infection at the insertion site, which could lead to serious complications.
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A nurse recalls an example of an immune-complex-mediated disease is:
- A. Bronchial asthma
- B. Contact dermatitis
- C. Serum sickness
- D. Rheumatoid arthritis
Correct Answer: C
Rationale: The correct answer is C: Serum sickness. Serum sickness is characterized by the formation of immune complexes in response to certain medications or proteins. These immune complexes can deposit in tissues, leading to inflammation and tissue damage. Bronchial asthma (Choice A) is a chronic inflammatory condition of the airways not primarily mediated by immune complexes. Contact dermatitis (Choice B) is a type IV hypersensitivity reaction mediated by T cells, not immune complexes. Rheumatoid arthritis (Choice D) is an autoimmune disease where antibodies target self-antigens, but it is not primarily mediated by immune complexes.
A patient is receiving chloroquine (Aralen) for extraintestinal amebiasis. Which of the following medications should be administered with chloroquine?
- A. Iodoquinol (Yodoxin)
- B. Metronidazole (Flagyl)
- C. Metyrosine (Demser)
- D. Carbamazepine (Tegretol)
Correct Answer: B
Rationale: The correct answer is B: Metronidazole (Flagyl). When treating extraintestinal amebiasis, chloroquine is often used in combination with metronidazole to ensure the eradication of the parasite. Metronidazole helps to target the infection more effectively. Choices A, C, and D are incorrect. Iodoquinol (Yodoxin) is another antiprotozoal agent but is not typically used in combination with chloroquine for amebiasis. Metyrosine (Demser) is used in the management of pheochromocytoma, and carbamazepine (Tegretol) is an anticonvulsant and mood-stabilizing drug, neither of which are indicated for extraintestinal amebiasis.
A patient who was frequently homeless over the past several years has begun a drug regimen consisting solely of isoniazid (INH). What is this patient's most likely diagnosis?
- A. Active tuberculosis
- B. Latent tuberculosis
- C. Mycobacterium avium complex
- D. Human immunodeficiency virus
Correct Answer: A
Rationale: The correct answer is A: Active tuberculosis. Given the patient's history of homelessness and initiation of isoniazid (INH) treatment, the most likely diagnosis is active tuberculosis. Isoniazid is a first-line medication used in the treatment of active tuberculosis. Latent tuberculosis (choice B) would not typically necessitate treatment with isoniazid alone. Mycobacterium avium complex (choice C) is not typically treated with isoniazid alone. Human immunodeficiency virus (choice D) is a risk factor for developing tuberculosis but is not the primary diagnosis in this patient scenario.
The patient should be taught that an improvement in symptoms will likely be noticed within
- A. 48 hours.
- B. a week to 10 days.
- C. 2 to 3 weeks.
- D. 4 to 6 weeks.
Correct Answer: C
Rationale: When taking isoniazid and rifampin for active tuberculosis, patients should be taught that an improvement in symptoms will likely be noticed within 2 to 3 weeks. Choice A (48 hours) is too soon to expect significant improvement in symptoms. Choice B (a week to 10 days) is also too early for noticeable improvement with this medication regimen. Choice D (4 to 6 weeks) is too far out to expect a noticeable improvement in symptoms.
A 45-year-old client is admitted with new-onset status epilepticus. What is the priority nursing intervention?
- A. Administer IV fluids and monitor electrolytes.
- B. Administer antiepileptic medications as prescribed.
- C. Ensure a patent airway and prepare for possible intubation.
- D. Monitor the client for signs of hypotension.
Correct Answer: C
Rationale: The correct answer is C. In a client with new-onset status epilepticus, the priority nursing intervention is to ensure a patent airway and prepare for possible intubation. This is crucial to prevent hypoxia and further complications. Administering IV fluids and monitoring electrolytes (choice A) can be important but ensuring airway patency takes precedence. Administering antiepileptic medications (choice B) is essential but only after securing the airway. Monitoring for hypotension (choice D) is also important but not the priority when managing status epilepticus.