Nokea
A nurse is completing a nutritional status of a patient who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply.
- A. Serum albumin level
- B. Weight history
- C. White blood cell count
- D. Body mass index E) Blood urea nitrogen (BUN) level
Correct Answer: A
Rationale: The correct answer is A: Serum albumin level. Serum albumin is an important indicator of nutritional status, as low levels may indicate malnutrition or inflammation commonly seen in AIDS patients. Weight history (B) is also relevant as weight changes can reflect nutritional status. White blood cell count (C) is not directly related to nutritional status. Body mass index (D) is a calculation based on weight and height, not a direct measure of nutritional status. Blood urea nitrogen (E) is a measure of kidney function, not a specific indicator of nutritional status. Therefore, the nurse should primarily focus on assessing the patient's serum albumin level for nutritional status evaluation in this case.
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Which findings should the nurse follow up on afterremoval of a catheter from a patient? (Select allthat apply.)
- A. Increasing fluid intake
- B. Dribbling of urine
- C. Voiding in small amounts
- D. Voiding within 6 hours of catheter removal
Correct Answer: B
Rationale: The correct answer is B: Dribbling of urine. This finding should be followed up on after catheter removal because it may indicate urinary retention or incomplete bladder emptying, which can lead to complications such as urinary tract infection.
A: Increasing fluid intake is important for overall hydration but is not a specific finding that requires follow-up after catheter removal.
C: Voiding in small amounts may be a normal response initially after catheter removal and does not necessarily indicate a problem.
D: Voiding within 6 hours of catheter removal is a positive sign of bladder function recovery and does not require immediate follow-up.
A patient diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this patient?
- A. The hearing loss will likely resolve with time after the drug is discontinued.
- B. The patients hearing loss and tinnitus are irreversible at this point.
- C. The patients tinnitus is likely multifactorial, and not directly related to aspirin use.
- D. The patients tinnitus will abate as tolerance to aspirin develops.
Correct Answer: B
Rationale: The correct answer is B because hearing loss and tinnitus caused by aspirin are typically irreversible. Aspirin is known to cause ototoxicity, which can lead to permanent damage to the auditory system. The nurse should inform the patient that the hearing loss and tinnitus may not improve even after discontinuing aspirin.
Choice A is incorrect because hearing loss caused by aspirin is usually permanent. Choice C is incorrect because aspirin is a known cause of tinnitus and hearing loss. Choice D is incorrect because tolerance to aspirin does not prevent or reverse ototoxic effects like tinnitus and hearing loss.
The nurse is concerned about pulmonary aspiration when providing the patient with an intermittent tube feeding. Which action is thepriority?
- A. Observe the color of gastric contents.
- B. Verify tube placement before feeding.
- C. Add blue food coloring to the enteral formula.
- D. Run the formula over 12 hours to decrease overload.
Correct Answer: B
Rationale: The correct answer is B because verifying tube placement before feeding is essential to prevent pulmonary aspiration. If the tube is not correctly positioned in the stomach, there is a risk of feeding going into the lungs. Observing the color of gastric contents (A) may not always indicate correct placement. Adding blue food coloring (C) is unnecessary and could cause confusion. Running the formula over 12 hours (D) does not address the risk of pulmonary aspiration and does not ensure proper tube placement.
During discharge teaching the nurse realizes that the patient is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene most appropriately in this situation?
- A. Ask the social worker to investigate alternative housing arrangements.
- B. Ask the social worker to investigate community support agencies.
- C. Encourage the patient to explore surgical corrections for the vision problem.
- D. Arrange for referral to a rehabilitation facility for vision training.
Correct Answer: D
Rationale: The correct answer is D. The nurse should arrange for a referral to a rehabilitation facility for vision training. This option directly addresses the patient's inability to read medication bottles accurately due to a vision problem. Vision training can help improve the patient's ability to manage medication independently.
A: Asking the social worker to investigate alternative housing arrangements is not relevant to the patient's vision problem affecting medication management.
B: Asking the social worker to investigate community support agencies may not directly address the patient's vision issue and medication management.
C: Encouraging the patient to explore surgical corrections for the vision problem is not appropriate without considering less invasive options first, such as vision training.
The nurse notes that a patient has a history of fibroids and is aware that this term refers to a benign tumor of the uterus. What is a more appropriate term for a fibroid?
- A. Bartholins cyst
- B. Dermoid cyst
- C. Hydatidiform mole
- D. Leiomyoma
Correct Answer: D
Rationale: The correct answer is D: Leiomyoma. A leiomyoma is the medical term for a fibroid, which is a benign tumor of the uterus composed of smooth muscle tissue. This term is more appropriate as it specifically refers to fibroids.
A: Bartholins cyst is a fluid-filled swelling in the Bartholin's gland, not related to fibroids.
B: Dermoid cyst is a type of ovarian cyst containing tissues like hair, teeth, and skin, not related to fibroids.
C: Hydatidiform mole is an abnormal growth of tissue in the uterus that forms during pregnancy, not related to fibroids.