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A nurse is preparing to document a patient whohas chest pain. Which information is critical for the nurse to include?
- A. The family is a “pain.”
- B. Pupils equal and reactive to light
- C. Had poor results from the pain medication
- D. Sharp pain of 8 on a scale of 1 to 10
Correct Answer: D
Rationale: The correct answer is D because documenting the patient's pain intensity using a pain scale (8 out of 10) is crucial for assessing the severity of the chest pain. This information helps in determining the appropriate intervention and monitoring the effectiveness of treatment. Choice A is irrelevant as it does not provide any useful information about the patient's condition. Choice B is important for neurological assessment but not specifically related to chest pain. Choice C is not as critical as knowing the current pain level.
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A patient with otosclerosis has significant hearing loss. What should the nurse do to best facilitate communication with the patient?
- A. Sit or stand in front of the patient when speaking.
- B. Use exaggerated lip and mouth movements when talking.
- C. Stand in front of a light or window when speaking.
- D. Say the patients name loudly before starting to talk.
Correct Answer: A
Rationale: The correct answer is A: Sit or stand in front of the patient when speaking. This choice is correct because it allows the patient with otosclerosis to directly see the nurse's face and lip movements, aiding in lip-reading and understanding speech. Sitting or standing in front of the patient also ensures better eye contact and reduces background noise interference.
Choice B is incorrect because exaggerated lip and mouth movements may distort speech and make it harder for the patient to understand. Choice C is incorrect because standing in front of a light or window can create glare and make it difficult for the patient to see the nurse's face clearly. Choice D is incorrect because saying the patient's name loudly before starting to talk does not directly address the communication needs of a patient with otosclerosis.
A patient has come into the free clinic asking to be tested for HIV infection. The patient asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the AIDS virus are present in the blood, this indicates what?
- A. The patient is immune to HIV.
- B. The patients immune system is intact.
- C. The patient has AIDS-related complications.
- D. The patient has been infected with HIV.
Correct Answer: D
Rationale: The correct answer is D: The patient has been infected with HIV. Antibodies to the AIDS virus in the blood indicate a past or current infection with HIV. This is because the body produces antibodies in response to the presence of the virus.
A: The patient is immune to HIV is incorrect because antibodies indicate exposure, not immunity.
B: The patient's immune system is intact is incorrect because the presence of antibodies does not necessarily reflect the overall functionality of the immune system.
C: The patient has AIDS-related complications is incorrect because the presence of antibodies does not directly indicate the presence of AIDS-related complications.
A patient diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the patients care, the nurse should be aware that the effects of the tumor will primarily depend on what variable?
- A. Whether the tumor utilizes aerobic or anaerobic respiration
- B. The specific hormones secreted by the tumor
- C. The patients pre-existing health status
- D. Whether the tumor is primary or the result of metastasis
Correct Answer: B
Rationale: The correct answer is B: The specific hormones secreted by the tumor. Pituitary adenomas are known to secrete hormones that can lead to various endocrine disorders. Understanding the specific hormones secreted by the tumor is crucial in determining the clinical manifestations and planning appropriate treatment. Choices A, C, and D are incorrect because the primary determinant of the effects of the tumor in this case is the hormonal activity rather than whether the tumor uses aerobic or anaerobic respiration, the patient's pre-existing health status, or whether the tumor is primary or metastatic.
The nurse is administering eye drops to a patient with glaucoma. After instilling the patients first medication, how long should the nurse wait before instilling the patients second medication into the same eye?
- A. 30 seconds
- B. 1 minute
- C. 3 minutes
- D. 5 minutes
Correct Answer: C
Rationale: The correct answer is C: 3 minutes. After administering the first eye drop, waiting for 3 minutes before instilling the second medication allows for proper absorption and effectiveness of each medication. This interval prevents dilution or interaction between the medications. Option A (30 seconds) is too short, not allowing sufficient time for absorption. Option B (1 minute) is also inadequate for proper absorption. Option D (5 minutes) is unnecessarily long and may lead to patient discomfort or inconvenience.
A patient has returned to the floor after undergoing a transurethral resection of the prostate (TURP). The patient has a continuous bladder irrigation system in place. The patient tells you he is experiencing bladder spasms and asks what you can do to relieve his discomfort. What is the most appropriate nursing action to relieve the discomfort of the patient?
- A. Apply a cold compress to the pubic area.
- B. Notify the urologist promptly.
- C. Irrigate the catheter with 30 to 50 mL of normal saline as ordered.
- D. Administer a smooth-muscle relaxant as ordered.
Correct Answer: D
Rationale: Rationale: Administering a smooth-muscle relaxant is the most appropriate nursing action to relieve bladder spasms post-TURP. The smooth-muscle relaxant helps relax the bladder muscles, reducing spasms and discomfort. Applying a cold compress (choice A) may provide temporary relief but won't address the underlying cause. Notifying the urologist (choice B) is important but not the immediate action for relieving spasms. Irrigating the catheter with normal saline (choice C) may not effectively address the spasms. Administering a smooth-muscle relaxant is the best choice for prompt relief.