Nokea
A nurse is caring for a toddler. The nurse's observations are as follows: Heart rate: 150/min, Temperature: 38.9°C (102°F), Respiratory rate: 28/min, Oxygen saturation: 96% on room air, Blood Pressure: 90/43 mm Hg. What should the nurse do next? What should the nurse do next for toddler vital signs?
- A. Monitor the toddler's vital signs closely.
- B. Administer supplemental oxygen.
- C. Notify the healthcare provider.
- D. Reassess the toddler in 15 minutes.
Correct Answer: A
Rationale: Rationale: Option A is correct as the toddler's vital signs are within acceptable ranges. The heart rate, respiratory rate, and oxygen saturation are normal for a toddler. The elevated temperature may indicate a fever, but it is not alarming. The blood pressure is slightly low but still acceptable. Therefore, the nurse should monitor the toddler's vital signs closely to assess for any changes. Administering oxygen, notifying the healthcare provider, or reassessing in 15 minutes are not necessary at this point as the vital signs do not indicate immediate concern. Monitoring closely allows for timely detection of any deterioration or improvement in the toddler's condition.
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A nurse is caring for a patient who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider? Which lab value should the nurse report during chemotherapy?
- A. Hemoglobin 12 g/dL
- B. Platelet count 50,000/mm3
- C. WBC 8,000/mm3
- D. Serum creatinine 1.0 mg/dL
Correct Answer: B
Rationale: The correct answer is B: Platelet count 50,000/mm3. During chemotherapy, patients are at risk for developing thrombocytopenia, a condition characterized by low platelet count. Thrombocytopenia can lead to increased risk of bleeding and bruising. Therefore, a platelet count of 50,000/mm3 is concerning and should be reported to the provider for further evaluation and management.
A: Hemoglobin of 12 g/dL is within normal range and not typically a concern during chemotherapy.
C: WBC count of 8,000/mm3 is within normal range and may not be a priority during chemotherapy unless there are other concerning symptoms.
D: Serum creatinine of 1.0 mg/dL is within normal range and not directly related to chemotherapy effects on the patient's blood counts.
A nurse is providing teaching to a patient who has stable angina and a new prescription for nitroglycerin oral, sustained-release capsules. Which of the following instructions should the nurse give? What instructions should the nurse give for nitroglycerin capsules?
- A. Take one capsule at the onset of anginal pain.
- B. Take the medication with meals.
- C. Stop taking the medication if side effects are troublesome.
- D. Swallow the capsules whole.
Correct Answer: D
Rationale: The correct answer is D: Swallow the capsules whole. Nitroglycerin oral, sustained-release capsules should be swallowed whole without crushing or chewing to ensure the medication is released slowly over time. If the capsules are broken or chewed, the full dose may be released at once, leading to a rapid drop in blood pressure. Choice A is incorrect because nitroglycerin capsules are not meant to be taken at the onset of pain, but as a preventive measure. Choice B is incorrect as there is no specific instruction to take the medication with meals. Choice C is incorrect as stopping medication abruptly can be dangerous, and patients should consult their healthcare provider before making any changes.
A nurse is caring for a patient who is receiving mechanical ventilation. Which of the following actions should the nurse take to prevent ventilator-associated pneumonia? Which action prevents ventilator-associated pneumonia?
- A. Perform oral care every 12 hours.
- B. Keep the head of the bed elevated to 30-45 degrees.
- C. Administer antibiotics prophylactically.
- D. Change the ventilator circuit daily.
Correct Answer: B
Rationale: The correct answer is B: Keep the head of the bed elevated to 30-45 degrees. Elevating the head of the bed helps prevent aspiration, which is a significant risk factor for ventilator-associated pneumonia. This position promotes proper lung expansion and drainage of secretions, reducing the likelihood of bacterial growth in the lungs. Performing oral care every 12 hours (A) is important for oral hygiene but does not directly prevent ventilator-associated pneumonia. Administering antibiotics prophylactically (C) can lead to antibiotic resistance and is not recommended routinely. Changing the ventilator circuit daily (D) is important for infection control but does not directly prevent ventilator-associated pneumonia.
A nurse is educating a patient with binge eating disorder and morbid obesity who has been prescribed orlistat. Which of the following statements, if made by the patient, would indicate that they understand the teaching? Which statement indicates understanding of orlistat teaching?
- A. I will stop taking orlistat and call my doctor if my urine gets darker in color.
- B. I will take my dose of orlistat every morning an hour before breakfast.
- C. I will feel less hungry during meals while I am taking orlistat.
- D. I will eat a no-fat diet to prevent side effects from the medication.
Correct Answer: A
Rationale: The correct answer is A: "I will stop taking orlistat and call my doctor if my urine gets darker in color." This statement indicates understanding because dark urine could indicate a potentially serious side effect of orlistat, such as liver problems. Stopping the medication and seeking medical advice in such a situation is crucial for the patient's safety.
Explanation for other choices:
B: Taking orlistat with a meal containing fat is recommended, not on an empty stomach before breakfast.
C: Orlistat does not suppress appetite; it works by blocking the absorption of fat in the intestine.
D: While reducing fat intake is recommended to decrease side effects, a no-fat diet is not necessary and could lead to nutrient deficiencies.
E, F, G: No additional choices provided.
History & Physical (0700hrs)
Date: 06/28/0X
• Client presented to the clinic reporting pelvic pain, dysmenorrhea, dyspareunia, and pain with defecation.
• Vaginal examination reveals fixed, palpable nodules with a retroverted uterus.
• Imaging reveals endometrial lesions on the ovaries, uterosacral ligaments, and round ligaments.
• Endometriosis diagnosed.
Provider's Prescriptions (0700hrs)
• Nafarelin 200 mcg: 1 spray intranasally every morning and 1 spray in the opposite nostril every evening.
Nurse's Notes (0700hrs)
• Client reports adherence to nafarelin regimen without missing doses.
• Client verbalizes irritation in the nasal mucosa.
• Reports feeling better overall with decreased dyspareunia.
• Notes decreased pain during bowel movements.
• Reports decreased pelvic pain and the absence of menstruation last month.
• Mentions experiencing headaches, increased acne, and reduced sex drive since starting treatment.
• Client observes a decrease in breast size.
Scenario:
A nurse is caring for a 32-year-old female client who was recently diagnosed with endometriosis. The client is in the clinic for a follow-up visit after beginning nafarelin treatment.
Setting: Clinic
Which of the following manifestations reported by the client should the nurse identify as a therapeutic effect of the nafarelin? (Select all that apply.)
- A. CNS manifestations
- B. Pain level during sexual intercourse
- C. Nasal mucosa changes
- D. Breast changes
- E. Missed previous month's menstrual cycle
- F. Dermatological manifestations
Correct Answer: B,E
Rationale: The correct answers are B and E. Nafarelin is a gonadotropin-releasing hormone (GnRH) agonist used to treat endometriosis by suppressing estrogen production, thereby reducing symptoms like pain during intercourse (choice B) and causing missed menstrual cycles (choice E). These are therapeutic effects. Choices A, C, D, and F are incorrect because CNS manifestations, nasal mucosa changes, breast changes, and dermatological manifestations are not commonly reported therapeutic effects of nafarelin. Thus, options A, C, D, and F can be ruled out.