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A nurse is caring for a group of patients. Which patient will the nurse seefirst?
- A. Patient receiving total parenteral nutrition of 2-in-1 for 50 hours
- B. Patient receiving total parenteral nutrition infusing with same tubing for 26 hours
- C. Patient receiving continuous enteral feeding with same feeding bag for 12 hours
- D. Patient receiving continuous enteral feeding with same tubing for 24 hours
Correct Answer: B
Rationale: The correct answer is B because the nurse should prioritize the patient who has been receiving total parenteral nutrition (TPN) infusing with the same tubing for 26 hours. This patient needs to be seen first to monitor for any potential complications or issues related to TPN administration. Choice A can be ruled out because 50 hours is longer than 26 hours. Choices C and D involve enteral feeding, which is important but generally less critical than TPN. Additionally, choice D has a shorter duration than choice B. Therefore, choice B is the most time-sensitive and critical patient to assess first.
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A nurse is caring for a patient with a continenturinary reservoir. Which action will the nurse take?
- A. Teach the patient how to self-cath the pouch.
- B. Teach the patient how to perform Kegel exercises.
- C. Teach the patient how to change the collection pouch.
- D. Teach the patient how to void using the Valsalva technique. In a continent urinary reservoir, the ileocecal valve creates a one-way valve in the pouch through which a catheter is inserted through the stoma to empty the urine from the pouch. Patients must be willing and able to catheterize the pouch 4 to 6 times a day for the rest of their lives. The second type of continent urinary diversion is called an orthotopic neobladder, which uses an ileal pouch to replace the bladder. Anatomically, the pouch is in the same position as the bladder was before removal, allowing a patient to void through the urethra using a Valsalva technique. In a ureterostomy or ileal conduit the patient has no sensation or control over the continuous flow of urine through the ileal conduit, requiring the effluent (drainage) to be collected in a pouch. Kegel exercises are ineffective for a patient with a continent urinary reservoir.
Correct Answer: A
Rationale: The correct answer is A: Teach the patient how to self-cath the pouch. In a continent urinary reservoir, patients need to catheterize the pouch several times a day. This is essential for emptying the urine from the pouch as the ileocecal valve creates a one-way valve. Teaching the patient how to self-catheterize ensures proper and timely drainage, preventing complications like urinary retention. Self-catheterization also empowers the patient to take an active role in managing their continence.
Summary of other choices:
B: Kegel exercises are ineffective for a patient with a continent urinary reservoir as they do not address the need for catheterization.
C: Changing the collection pouch is not the primary action needed for a continent urinary reservoir. Catheterization is essential for drainage.
D: The Valsalva technique is not appropriate for voiding in a continent urinary reservoir. Catheterization is the recommended method for emptying the pouch.
A student nurse is doing clinical hours at an OB/GYN clinic. The student is helping to develop a plan of care for a patient with gonorrhea who has presented at the clinic. The student should include which of the following in the care plan for this patient?
- A. The patient may benefit from oral contraceptives.
- B. The patient must avoid use of tampons.
- C. The patient is susceptible to urinary incontinence.
- D. The patient should also be treated for chlamydia.
Correct Answer: D
Rationale: Correct Answer: D - The patient should also be treated for chlamydia.
Rationale:
1. Gonorrhea and chlamydia often coexist, so it is crucial to treat both infections to prevent complications.
2. Treating only gonorrhea may not fully resolve the patient's symptoms or prevent reinfection.
3. Dual therapy for gonorrhea and chlamydia is recommended to ensure optimal care for the patient.
Summary of Incorrect Choices:
A: The patient may benefit from oral contraceptives - This is not directly related to the treatment of gonorrhea.
B: The patient must avoid use of tampons - This is not a standard recommendation for managing gonorrhea.
C: The patient is susceptible to urinary incontinence - This is not a typical complication of gonorrhea.
A patient diagnosed with Bells palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions?
- A. Applying a protective eye shield at night
- B. Chewing on the affected side to prevent unilateral neglect
- C. Avoiding the use of analgesics whenever possible
- D. Avoiding brushing the teeth
Correct Answer: A
Rationale: Rationale for Correct Answer A: Applying a protective eye shield at night is crucial for a patient with Bell's palsy to prevent corneal abrasions due to incomplete eyelid closure. This action helps protect the eye from dryness and injury, which can occur due to decreased blinking and moisture. It is essential to maintain eye health and prevent complications.
Summary of Incorrect Choices:
B: Chewing on the affected side does not prevent unilateral neglect in Bell's palsy. Instead, encouraging balanced chewing and facial exercises would be more beneficial.
C: Avoiding the use of analgesics is not necessary for Bell's palsy management unless contraindicated, as pain management may be required for associated symptoms.
D: Avoiding brushing the teeth is not recommended. Good oral hygiene is important for overall health, including maintaining oral health during Bell's palsy.
A patients decline in respiratory and renal function has been attributed to Goodpasture syndrome, which is a type II hypersensitivity reaction. What pathologic process underlies the patients health problem?
- A. Antigens have bound to antibodies and formed inappropriate immune complexes.
- B. The patients body has mistakenly identified a normal constituent of the body as foreign.
- C. Sensitized T cells have caused cell and tissue damage.
- D. Mast cells have released histamines that directly cause cell lysis.
Correct Answer: B
Rationale: The correct answer is B because in Goodpasture syndrome, the patient's immune system mistakenly targets normal constituents of the body, specifically the basement membrane of the kidneys and lungs. This autoimmune response leads to inflammation and damage in these organs, resulting in respiratory and renal dysfunction.
Choice A is incorrect as immune complexes are not the primary mechanism in Goodpasture syndrome. Choice C is incorrect as it refers to T cell-mediated immune responses, which are not the main drivers in this condition. Choice D is incorrect as histamine release and cell lysis are not the main processes involved in Goodpasture syndrome.
A nurse is sitting at the patient’s bedside takinga nursing history. Which zone of personal space is the nurse using?
- A. Socio-consultative
- B. Personal
- C. Intimate
- D. Public
Correct Answer: B
Rationale: The nurse sitting at the patient's bedside is using the personal zone of personal space, which ranges from 18 inches to 4 feet. This distance allows for a close interaction suitable for taking a nursing history while maintaining a professional yet personal connection. The socio-consultative zone (A) is 4-12 feet, more appropriate for professional interactions. The intimate zone (C) is 0-18 inches, too close for an initial nursing history. The public zone (D) is 12 feet or more, too distant for a personal conversation.