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A nurse is preparing a patient for allergy skin testing. Which of the following precautionary steps is most important for the nurse to follow?
- A. The patient must not have received an immunization within 7 days.
- B. The nurse should administer albuterol 30 to 45 minutes prior to the test.
- C. Prophylactic epinephrine should be administered before the test.
- D. Emergency equipment should be readily available.
Correct Answer: D
Rationale: The correct answer is D. Having emergency equipment readily available is crucial during allergy skin testing as it can lead to severe allergic reactions. This precaution ensures prompt intervention in case of anaphylaxis. Other choices are incorrect because: A) Recent immunizations do not directly impact the skin testing process. B) Administering albuterol is not a standard pre-test requirement. C) Prophylactic epinephrine is not routinely given before allergy skin testing.
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Which nursing actions will the nurse implementwhen collecting a urine specimen from a patient? (Select all that apply.)
- A. Growing urine cultures for up to 12 hours
- B. Labeling all specimens with date, time, and initials
- C. Allowing the patient adequate time and privacy to void
- D. Wearing gown, gloves, and mask for all specimen handling
Correct Answer: B
Rationale: The correct answer is B: Labeling all specimens with date, time, and initials. This is important for proper identification and tracking of the specimen.
- Choice A is incorrect because urine cultures typically take longer than 12 hours to grow.
- Choice C is incorrect as privacy is important but not a specific action related to urine specimen collection.
- Choice D is incorrect as wearing gown, gloves, and mask may not be necessary for routine urine specimen collection, unless there are specific precautions needed.
A 54-year-old has a diagnosis of breast cancer and is tearfully discussing her diagnosis with the nurse. The patient states, They tell me my cancer is malignant, while my coworkers breast tumor was benign. I just dont understand at all. When preparing a response to this patient, the nurse should be cognizant of what characteristic that distinguishes malignant cells from benign cells of the same tissue type?
- A. Slow rate of mitosis of cancer cells
- B. Different proteins in the cell membrane
- C. Differing size of the cells
- D. Different molecular structure in the cells
Correct Answer: D
Rationale: The correct answer is D: Different molecular structure in the cells. Malignant cells have alterations in their molecular structure, leading to uncontrolled growth and invasion of surrounding tissues, while benign cells retain their normal molecular structure and do not invade nearby tissues. This distinction is crucial in understanding why malignant cells are cancerous and pose a greater risk compared to benign cells.
Other choices are incorrect because:
A: Slow rate of mitosis of cancer cells - Malignant cells actually have a rapid rate of mitosis, contributing to their uncontrolled growth.
B: Different proteins in the cell membrane - While there may be differences in proteins, the molecular structure is a more fundamental difference between malignant and benign cells.
C: Differing size of the cells - Cell size alone is not a definitive characteristic that distinguishes between malignant and benign cells; molecular structure plays a more significant role.
Which of the following nursing interventions would most likely facilitate effective communication with a hearing-impaired patient?
- A. Ask the patient to repeat what was said in order to evaluate understanding.
- B. Stand directly in front of the patient to facilitate lip reading.
- C. Reduce environmental noise and distractions before communicating.
- D. Raise the voice to project sound at a higher frequency.
Correct Answer: C
Rationale: The correct answer is C: Reduce environmental noise and distractions before communicating. This intervention is most likely to facilitate effective communication with a hearing-impaired patient because it creates an optimal environment for the patient to better focus on the communication. By reducing noise and distractions, the patient can more easily concentrate on the conversation and lip reading, if needed. This approach demonstrates sensitivity to the patient's needs and enhances the chances of successful communication.
The other choices are incorrect because:
A: Asking the patient to repeat what was said may cause frustration and does not address the environmental factors that can hinder communication.
B: Standing directly in front of the patient to facilitate lip reading may help, but it does not address the impact of environmental noise and distractions on communication.
D: Raising the voice to project sound at a higher frequency is not effective as it can distort speech and may not necessarily improve understanding for a hearing-impaired patient.
A patient with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea?
- A. Administer antidiarrheal medications on a scheduled basis, as ordered.
- B. Encourage the patient to eat three balanced meals and a snack at bedtime.
- C. Increase the patients oral fluid intake.
- D. Encourage the patient to increase his or her activity level.
Correct Answer: C
Rationale: The correct answer is C: Increase the patient's oral fluid intake. This is because severe diarrhea can lead to dehydration, which can be dangerous for patients with HIV infection. By increasing oral fluid intake, the patient can stay hydrated and prevent further complications. Administering antidiarrheal medications on a scheduled basis (Choice A) may provide temporary relief but does not address the underlying issue of dehydration. Encouraging the patient to eat balanced meals (Choice B) and increase activity level (Choice D) may be important for overall health but do not directly address the immediate concern of dehydration caused by severe diarrhea.
A clinic nurse is providing patient education prior to a patients scheduled palliative radiotherapy to her spine. At the completion of the patient teaching, the patient continues to ask the same questions that the nurse has already addressed. What is the plausible conclusion that the nurse should draw from this?
- A. The patient is not listening effectively.
- B. The patient is noncompliant with the plan of care.
- C. The patient may have a low intelligence quotient or a cognitive deficit.
- D. The patient has not achieved the desired learning outcomes.
Correct Answer: D
Rationale: The correct answer is D. The plausible conclusion the nurse should draw is that the patient has not achieved the desired learning outcomes.
1. The patient's repeated questions indicate a lack of understanding despite the nurse's teaching efforts.
2. This suggests that the patient has not grasped the information provided.
3. It does not necessarily mean the patient is not listening effectively, noncompliant, or has low intelligence.
4. The focus should be on reassessing the teaching methods and providing additional support to help the patient achieve the desired learning outcomes.