Nokea
A nurse is checking orders. Which order shouldthe nurse question?
- A. A normal saline enema to be repeated every 4 hours until stool is produced
- B. A hypertonic solution enema for a patient with fluid volume excess
- C. A Kayexalate enema for a patient with severe hypokalemia
- D. An oil retention enema for a patient with constipation
Correct Answer: B
Rationale: The correct answer is B because giving a hypertonic solution enema to a patient with fluid volume excess can worsen the condition by drawing more fluid into the colon. This can lead to further fluid volume overload and electrolyte imbalances. The other choices are incorrect because:
A: Normal saline enema is appropriate for constipation.
C: Kayexalate enema is used to treat hyperkalemia, not hypokalemia.
D: Oil retention enema is indicated for constipation to soften stool.
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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 performing a cultural assessment usingthe ETHNIC mnemonic for communication. Which area will the nurse assess for the “H”?
- A. Health
- B. Healers
- C. History
- D. Homeland
Correct Answer: B
Rationale: The correct answer is B: Healers. In the ETHNIC mnemonic, "H" stands for Healers, where the nurse assesses the individual's traditional healers, healthcare practices, and preferences for seeking healthcare. This is important in understanding the individual's cultural beliefs and practices related to health and treatment. Assessing "Health" (A) may be important, but it does not specifically address traditional healers. "History" (C) focuses on the individual's cultural background rather than healthcare practices. "Homeland" (D) pertains to the individual's place of origin, which is not directly related to healthcare communication.
A nurse obtained a telephone order from a primarycare provider for a patient in pain. Which chart entry should the nurse document?
- A. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back.
- B. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN, read back.
- C. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.
- D. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN.
Correct Answer: C
Rationale: The correct answer is C because it includes all necessary components for a complete and accurate chart entry. The nurse documents the date and time of the order, the medication prescribed (Morphine, 2 mg, IV every 4 hours), the indication for use (incisional pain), the intended recipient (Dr. Day), the nurse's name (J. Winds), and confirmation of the read-back procedure. This entry ensures clarity, accountability, and proper communication among healthcare team members.
Choice A is incorrect because it misses the recipient of the order (Dr. Day) and only includes the nurse's name in the read-back. Choice B is incorrect because it lacks the recipient of the order and the confirmation of the read-back procedure with the primary care provider. Choice D is incorrect because it does not specify the primary care provider who gave the order and misses the read-back confirmation with the provider.
The nurse is performing an initial assessment of an older adult resident who has just relocated to the long-term care facility. During the nurses interview with the patient, she admits that she drinks around 20 ounces of vodka every evening. What types of cancer does this put her at risk for? Select all that apply.
- A. Malignant melanoma
- B. Brain cancer
- C. Breast cancer
- D. Esophageal cancer E) Liver cancer
Correct Answer: D
Rationale: The correct answer is D: Esophageal cancer. Alcohol consumption is a known risk factor for developing esophageal cancer. Ethanol, a component of alcohol, can damage the cells lining the esophagus and lead to the development of cancer over time.
Incorrect choices:
A: Malignant melanoma - Alcohol consumption is not directly linked to the development of malignant melanoma, a type of skin cancer.
B: Brain cancer - There is no strong evidence linking alcohol consumption to an increased risk of brain cancer.
C: Breast cancer - While excessive alcohol consumption is a risk factor for breast cancer, the primary association is with esophageal cancer in this case.
E: Liver cancer - While alcohol abuse can lead to liver damage and increase the risk of liver cancer, the question specifies the types of cancer the patient is at risk for due to alcohol consumption, not the general risks associated with alcohol abuse.
The patient is having at least 75% of nutritional needs met by enteral feeding, so the health care provider has ordered the parenteral nutrition (PN) to be discontinued. However, the nurse notices that the PN infusion has fallen behind. What should the nurse do?
- A. Increase the rate to get the volume caught up before discontinuing.
- B. Stop the infusion as ordered.
- C. Taper infusion gradually.
- D. Hang 5% dextrose.
Correct Answer: C
Rationale: Rationale for Correct Answer (C - Taper infusion gradually):
1. Tapering the infusion gradually allows for a smooth transition off PN without causing metabolic disturbances.
2. Abruptly stopping PN can lead to hypoglycemia and electrolyte imbalances.
3. Increasing the rate may cause fluid overload or hyperglycemia.
4. Hanging 5% dextrose alone does not provide adequate nutrition and may not meet the patient's needs.