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A nurse is completing an OASIS data set on apatient. The nurse works in which area?
- A. Home health
- B. Intensive care unit
- C. Skilled nursing facility
- D. Long-term care facility
Correct Answer: A
Rationale: The correct answer is A: Home health. The Outcome and Assessment Information Set (OASIS) data set is specifically used in the home health care setting to assess the patient's condition and needs. This includes collecting data on the patient's health, functional status, and living environment to determine the appropriate care plan. In contrast, choices B, C, and D are incorrect because OASIS is not utilized in the intensive care unit, skilled nursing facility, or long-term care facility settings. These settings have their own assessment tools and documentation requirements that are different from OASIS used in home health care.
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A nurse is aware of the need to assess patients risks for anaphylaxis. What health care procedure constitutes the highest risk for anaphylaxis?
- A. Administration of the measles-mumps-rubella (MMR) vaccine
- B. Rapid administration of intravenous fluids
- C. Computed tomography with contrast solution
- D. Administration of nebulized bronchodilators
Correct Answer: C
Rationale: The correct answer is C: Computed tomography with contrast solution. This procedure involves the use of contrast agents that can trigger anaphylaxis due to the patient's allergic reaction to the contrast solution. Contrast solutions contain substances like iodine, which can cause severe allergic reactions in some individuals. Anaphylaxis is a life-threatening allergic reaction that can occur rapidly and requires immediate intervention. Assessing the risk for anaphylaxis during this procedure is crucial to prevent any potential harm to the patient.
Incorrect choices:
A: Administration of the measles-mumps-rubella (MMR) vaccine - While allergic reactions can occur with vaccines, the risk of anaphylaxis with MMR vaccine is lower compared to the contrast solution used in CT scans.
B: Rapid administration of intravenous fluids - Rapid IV fluid administration can cause fluid overload or electrolyte imbalances, but it is not typically associated with triggering anaphylaxis.
D: Administration of nebulized bronchodil
A nurse is teaching about the energy needed at rest to maintain life-sustaining activities for a specific period of time. What is the nurse discussing?
- A. Resting energy expenditure (REE)
- B. Basal metabolic rate (BMR)
- C. Nutrient density
- D. Nutrients
Correct Answer: B
Rationale: The correct answer is B: Basal metabolic rate (BMR). BMR refers to the minimum amount of energy required to maintain basic physiological functions at rest. It accounts for about 60-75% of total energy expenditure. It is essential for sustaining life-sustaining activities such as breathing, circulating blood, and maintaining body temperature.
Incorrect Choices:
A: Resting energy expenditure (REE) is the total amount of energy expended by the body while at rest, including BMR and additional energy for daily activities.
C: Nutrient density refers to the amount of nutrients per calorie in a food item, not the energy needed at rest.
D: Nutrients are essential substances in food required for growth, maintenance, and repair, but they do not specifically refer to the energy needed at rest.
A patient with Huntington disease has just been admitted to a long-term care facility. The charge nurse is creating a care plan for this patient. Nutritional management for a patient with Huntington disease should be informed by what principle?
- A. The patient is likely to have an increased appetite.
- B. The patient is likely to required enzyme supplements.
- C. The patient will likely require a clear liquid diet.
- D. The patient will benefit from a low-protein diet.
Correct Answer: D
Rationale: The correct answer is D - The patient will benefit from a low-protein diet. Patients with Huntington disease often experience difficulty swallowing and may have involuntary movements, leading to weight loss. A low-protein diet can help manage these symptoms and reduce the risk of aspiration pneumonia. This diet can also help control the chorea movements associated with the disease.
Choice A is incorrect as patients with Huntington disease often have reduced appetite due to swallowing difficulties. Choice B is incorrect as enzyme supplements are not typically indicated in the management of Huntington disease. Choice C is incorrect as a clear liquid diet is not suitable for meeting the nutritional needs of a patient with Huntington disease, who may already be at risk for malnutrition.
A patient got a sliver of glass in his eye when a glass container at work fell and shattered. The glass had to be surgically removed and the patient is about to be discharged home. The patient asks the nurse for a topical anesthetic for the pain in his eye. What should the nurse respond?
- A. Overuse of these drops could soften your cornea and damage your eye.
- B. You could lose the peripheral vision in your eye if you used these drops too much.
- C. Im sorry, this medication is considered a controlled substance and patients cannot take it home.
- D. I know these drops will make your eye feel better, but I cant let you take them home.
Correct Answer: A
Rationale: The correct answer is A. Overuse of topical anesthetics can soften the cornea and damage the eye. Topical anesthetics numb the eye, masking pain and potentially leading to overuse. This can prevent the patient from recognizing potential issues like infection or further injury. Additionally, prolonged use can interfere with the cornea's ability to heal properly. Choices B, C, and D are incorrect because they do not address the specific risks associated with using topical anesthetics in the eye. Option B focuses on peripheral vision loss, which is not a direct consequence of using topical anesthetics. Choice C mentions controlled substances, which is not relevant to the situation. Option D acknowledges the patient's request but does not educate the patient on the potential harm of overusing topical anesthetics.
A patient has undergone diagnostic testing and has been diagnosed with otosclerosis? What ear structure is primarily affected by this diagnosis?
- A. Malleus
- B. Stapes
- C. Incus
- D. Tympanic membrane
Correct Answer: B
Rationale: The correct answer is B: Stapes. Otosclerosis is a condition characterized by abnormal bone growth in the middle ear, causing the stapes bone to become fixed in place. This results in hearing loss due to the inability of the stapes to transmit sound vibrations to the inner ear. The malleus (choice A), incus (choice C), and tympanic membrane (choice D) are not primarily affected by otosclerosis. The malleus and incus are located in the middle ear but are not typically affected by otosclerosis. The tympanic membrane is part of the outer ear and is not directly involved in otosclerosis.