Nokea
A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing patient teaching prior to the patients discharge. In the event of an anaphylactic reaction, the nurse informs the patient that she should self-administer epinephrine in what site?
- A. Forearm
- B. Thigh
- C. Deltoid muscle
- D. Abdomen
Correct Answer: B
Rationale: The correct answer is B: Thigh. When administering epinephrine during an anaphylactic reaction, the thigh is the recommended site due to its large muscle mass and quick absorption rate. Steps: 1. Remove safety cap. 2. Firmly push the auto-injector against the thigh until it clicks. 3. Hold in place for a few seconds. 4. Seek medical help immediately. Rationale for incorrect choices: A: Forearm - Not recommended due to smaller muscle mass and slower absorption. C: Deltoid muscle - Not preferred as it may not provide as rapid absorption as the thigh. D: Abdomen - Not ideal due to potential fat layers that could affect absorption speed.
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A patient has returned to the post-surgical unit after vulvar surgery. What intervention should the nurse prioritize during the initial postoperative period?
- A. Placing the patient in high Fowlers position
- B. Administering sitz baths every 4 hours
- C. Monitoring the integrity of the surgical site
- D. Avoiding analgesics unless the patients pain is unbearable
Correct Answer: C
Rationale: The correct answer is C: Monitoring the integrity of the surgical site. This is the priority intervention as it ensures early detection of any complications like infection or bleeding. The nurse should assess for signs of infection, such as redness, swelling, or drainage, and monitor for any changes in the wound appearance. Placing the patient in high Fowler's position (A) may be beneficial for comfort but is not the priority. Administering sitz baths (B) may be helpful for comfort but should not be the priority over monitoring the surgical site. Avoiding analgesics (D) unless the pain is unbearable is not appropriate as pain management is essential for the patient's comfort and recovery.
Anti-infective prophylaxis is indicated for a pregnant patient with a history of mitral valve stenosis related to rheumatic heart disease because the patient is at risk of developing
- A. hypertension.
- B. postpartum infection.
- C. bacterial endocarditis.
- D. upper respiratory infections.
Correct Answer: C
Rationale: The correct answer is C: bacterial endocarditis. Mitral valve stenosis increases the risk of bacterial endocarditis due to turbulent blood flow and potential damage to the heart valve. Prophylactic antibiotics are recommended before certain procedures to prevent bacterial endocarditis in patients with underlying cardiac conditions.
Choice A, hypertension, is incorrect as mitral valve stenosis does not directly increase the risk of developing hypertension. Choice B, postpartum infection, is not directly related to the risk associated with mitral valve stenosis. Choice D, upper respiratory infections, is not a specific risk associated with mitral valve stenosis in pregnant patients.
A nurse is caring for an 8-year-old patient whois embarrassed about urinating in bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence?
- A. “Set your alarm clock to wake you every 2 hours, so you can get up to void.”
- B. “Line your bedding with plastic sheets to protect your mattress.”
- C. “Drink your nightly glass of milk earlier in the evening.”
- D. “Empty your bladder completely before going to bed.”
Correct Answer: C
Rationale: The correct answer is C: “Drink your nightly glass of milk earlier in the evening.” By suggesting the patient to drink milk earlier, it allows more time for the body to process and excrete the fluids before bedtime, reducing the likelihood of bedwetting. This intervention targets the root cause of the issue by addressing the timing of fluid intake.
Explanation for why the other choices are incorrect:
A: “Set your alarm clock to wake you every 2 hours, so you can get up to void.” This intervention disrupts the patient's sleep pattern and may not address the underlying cause of bedwetting.
B: “Line your bedding with plastic sheets to protect your mattress.” This intervention focuses on managing the consequences of bedwetting rather than preventing it.
D: “Empty your bladder completely before going to bed.” While important, this suggestion alone may not be sufficient to address the timing of fluid intake, which is crucial in reducing bedwetting frequency.
The nurse is reviewing the instructions given to a patient at 24 weeks’ gestation for a glucose challenge test (GCT). The nurse determines that the patient understands the teaching when she makes which statement?
- A. “I have to fast the night before the test.”
- B. “I will drink a sugary solution containing 100 g of glucose.”
- C. “I will have blood drawn at 1 hour after I drink the glucose solution.”
- D. “I should keep track of my baby’s movements between now and the test.”
Correct Answer: C
Rationale: The correct answer is C: “I will have blood drawn at 1 hour after I drink the glucose solution.” This statement demonstrates understanding of the GCT procedure. The glucose challenge test involves drinking a sugary solution, followed by blood drawn 1 hour later to measure blood glucose levels. This timing is crucial for assessing the body's ability to metabolize glucose, which helps in diagnosing gestational diabetes.
Explanation of why the other choices are incorrect:
A: “I have to fast the night before the test.” - This is incorrect as fasting is not required for the GCT.
B: “I will drink a sugary solution containing 100 g of glucose.” - This is incorrect as the GCT typically involves drinking a solution with a standardized amount of glucose, usually 50 g, not 100 g.
D: “I should keep track of my baby’s movements between now and the test.” - This is unrelated to the GCT procedure and does not demonstrate understanding of the
The nurse in a pediatric ICU is caring for a child who is dying of sickle cell anemia. The childs mother has been unable to eat or sleep and can talk only about her impending loss and the guilt she feels about the childs pain and suffering. What intervention has the highest priority?
- A. Allowing the patient to express her feelings without judging her
- B. Helping the patient to understand the phases of the grieving process
- C. Reassuring the patient that the childs death is not her fault
- D. Arranging for genetic counseling to inform the patient of her chances of having another child with the disease
Correct Answer: A
Rationale: The correct answer is A: Allowing the patient to express her feelings without judging her. This intervention has the highest priority as it focuses on providing emotional support and creating a safe space for the mother to express her emotions without feeling judged. In this situation, the mother is experiencing intense guilt and grief, and allowing her to talk about her feelings can help her process her emotions and cope with the impending loss. By listening actively and without judgment, the nurse can demonstrate empathy and compassion, which are crucial in supporting the mother through this difficult time.
Summary:
B: Helping the patient to understand the phases of the grieving process may be helpful, but it is not the highest priority at this moment.
C: Reassuring the patient that the child's death is not her fault is important, but the priority is to address the mother's emotional needs first.
D: Arranging for genetic counseling is not the highest priority at this time as the immediate focus should be on providing emotional support to the mother