Nokea
A nurse is caring for a patient after a coronary angiogram. Which of these actions taken by the nursing assistant would most require the nurse's immediate intervention?
- A. The nursing assistant fills the patient's pitcher with ice-cold drinking water
- B. The nursing assistant elevates the head of the bed to 60 degrees for a meal
- C. The nursing assistant refills the ice pack placed on the insertion site
- D. The nursing assistant places an extra pillow under the patient's head upon request
Correct Answer: B
Rationale: After a coronary angiogram, patients need to maintain bed rest and keep the head of the bed at no more than 30 degrees for 3-6 hours, depending on the insertion site. Elevating the head of the bed to 60 degrees for a meal could increase the risk of bleeding or complications at the insertion site. Refilling the ice pack placed on the insertion site is appropriate for managing potential swelling or discomfort. Filling the patient's pitcher with ice-cold drinking water is a standard care task. Placing an extra pillow under the patient's head upon request is a comfort measure and does not pose a risk to the patient's recovery.
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When analyzing the results of the urinalysis collected preoperatively from a child with epispadias scheduled for surgical repair, which finding should the nurse most likely expect to note?
- A. Hematuria
- B. Proteinuria
- C. Bacteriuria
- D. Glucosuria
Correct Answer: C
Rationale: Epispadias is a congenital defect characterized by the abnormal placement of the urethral orifice of the penis, often on the dorsum. This anatomical anomaly predisposes individuals to bacterial entry into the urinary tract, leading to bacteriuria. Hematuria, proteinuria, and glucosuria are not typically associated with epispadias. Hematuria refers to the presence of blood in the urine, proteinuria indicates protein in the urine, and glucosuria is the presence of glucose in the urine, none of which are commonly seen in epispadias.
A patient is being admitted to the ICU with a severe case of encephalitis. Which of these drugs would the nurse not expect to be prescribed for this condition?
- A. Acyclovir (Zovirax)
- B. Mannitol (Osmitrol)
- C. Lactated Ringer's
- D. Phenytoin (Dilantin)
Correct Answer: C
Rationale: In the treatment of encephalitis, medications like Acyclovir and Phenytoin are commonly prescribed. Acyclovir is an antiviral medication used to treat viral infections like herpes simplex virus, which can cause encephalitis. Phenytoin is an antiepileptic drug that may be used to manage seizures associated with encephalitis. Mannitol is a diuretic used to reduce intracranial pressure (ICP) by decreasing cerebral edema. Lactated Ringer's solution, on the other hand, is primarily used in fluid replacement therapy and may not be indicated if a patient is at risk for high ICP, as excessive fluid administration could worsen cerebral edema and increase ICP.
A patient with Meningitis is being treated with Vancomycin intravenously 3 times per day. The nurse notes that the urine output during the last 8 hours was 200mL. What is the nurse's priority action?
- A. Check the patient's last BUN levels
- B. Ask the patient to increase their fluid intake
- C. Ask the physician to order a diuretic
- D. Notify the physician of this finding
Correct Answer: D
Rationale: Vancomycin is a nephrotoxic drug and can cause impaired renal perfusion, which would lead to decreased urine output. This is a serious adverse effect that should be promptly reported to the physician. Checking the patient's last BUN levels (Choice A) may provide additional information but does not address the urgency of the situation. Asking the patient to increase fluid intake (Choice B) may not be appropriate if the cause is related to Vancomycin toxicity. Ordering a diuretic (Choice C) without physician evaluation can exacerbate the issue, making notifying the physician (Choice D) the most critical action to take.
Based on the information given, which patient would be an appropriate candidate for a closed MRI without contrast?
- A. A 20-year-old woman with unexplained joint pain and a low BMI.
- B. A 35-year-old woman with Multiple Sclerosis who is trying to conceive.
- C. A 67-year-old man who had open-heart surgery 4 years ago.
- D. A 40-year-old woman in a hypomanic state for the last 2 days.
Correct Answer: A
Rationale: The correct answer is the 20-year-old woman with unexplained joint pain and a low BMI. MRI can be used to diagnose musculoskeletal disorders, and this patient has no contraindications to an MRI. Choice B is incorrect because using MRI without contrast may not be ideal for a patient trying to conceive. Choice C is incorrect as the patient's past open-heart surgery may pose risks for an MRI without contrast. Choice D is incorrect since the patient's hypomanic state does not indicate a need for an MRI without contrast for joint pain.
After performing an assessment of an infant with bladder exstrophy, the nurse prepares a plan of care. The nurse identifies which problem as the priority for the infant?
- A. Urinary incontinence
- B. Impaired tissue integrity
- C. Inability to suck and swallow
- D. Lack of knowledge about the disease (parents)
Correct Answer: B
Rationale: In bladder exstrophy, the bladder is exposed and external to the body, leading to impaired tissue integrity related to the exposed bladder mucosa as the priority problem. Urinary incontinence is not a concern as the infant is not yet toilet trained. Inability to suck and swallow is unrelated to the disorder. While educating the parents about the condition is important, it is not the priority over addressing the immediate risk of impaired tissue integrity in the infant.