Nokea
A nurse is preparing to perform a central venous catheter (CVC) dressing change for a patient. What action should the nurse prioritize to minimize the risk of infection?
- A. Wearing sterile gloves and a mask during the dressing change
- B. Cleaning the insertion site with alcohol-based antiseptic solution
- C. Removing the old dressing and applying a new dressing using sterile technique
- D. Changing the CVC tubing along with the dressing to prevent contamination
Correct Answer: C
Rationale: The nurse should prioritize removing the old dressing and applying a new dressing using sterile technique to minimize the risk of infection during a central venous catheter (CVC) dressing change. This is because the most critical step in preventing infection is maintaining a clean and sterile environment around the CVC insertion site. By using sterile technique, the nurse can reduce the introduction of microorganisms that could potentially lead to infection. Wearing sterile gloves and cleaning the insertion site with an alcohol-based antiseptic solution are important steps as well, but the key priority lies in applying the new dressing using sterile technique to prevent contamination and reduce the risk of infection.
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The nurse suspects that a client has multiple myeloma based on the client's major presenting symptom and the analysis of laboratory results. What classic manifestation for multiple myeloma does the nurse assess for?
- A. Debilitating fatigue
- B. Gradual muscle paralysis
- C. Bone pain in the back of the ribs
- D. Severe thrombocytopenia
Correct Answer: C
Rationale: Bone pain in the back of the ribs is a classic manifestation of multiple myeloma. Multiple myeloma is a type of cancer that primarily affects plasma cells in the bone marrow, leading to weakened bones and bone pain. Patients with multiple myeloma often experience bone pain in areas such as the ribs, spine, and pelvis. The bone pain is typically persistent and worsens with movement or pressure. Additionally, other common symptoms of multiple myeloma include anemia, kidney damage, recurrent infections, and elevated calcium levels in the blood.
Which of the following structures is responsible for propelling food from the oral cavity to the stomach through coordinated muscular contractions?
- A. Tongue
- B. Pharynx
- C. Esophagus
- D. Epiglottis
Correct Answer: C
Rationale: The esophagus is responsible for propelling food from the oral cavity to the stomach through a series of coordinated muscular contractions. These contractions are known as peristalsis. The esophagus is a muscular tube connecting the throat (pharynx) to the stomach and plays a crucial role in moving food bolus from the mouth to the stomach for digestion. The tongue helps in the chewing and swallowing of food, the pharynx is involved in the passage of food and air, and the epiglottis helps prevent food from entering the airways during swallowing. However, it is the esophagus that actively moves the food to the stomach.
When the patient turned 69 years old, Orinase was discontinued and NPH insulin is prescribed for her. After several months, she is determined to be suffering from sumogyi effect. Which of the following conditons will most likely result when the patient is receiving too much insulin?
- A. Developing an elevation of the blood glucose level
- B. Producing even more insulin
- C. Becoming resistant to insulin
- D. Conserving excessive amount of fluid
Correct Answer: A
Rationale: When a patient is receiving too much insulin, the most likely result is hypoglycemia, not hyperglycemia. The excess insulin causes the blood glucose level to drop too low, leading to symptoms such as sweating, tremors, confusion, and in severe cases, seizures. The body responds to hypoglycemia by releasing counterregulatory hormones such as glucagon, epinephrine, and cortisol, which work to increase the blood glucose level. This rebound effect, known as the Somogyi effect, can result in the patient experiencing high blood glucose levels after a period of insufficient glucose supply due to excessive insulin administration.
Nurse Rey with the members of the team. from a tertiary hospital is going for their annual outreach program Operation TULI". There were 3000 patients who came in the morning with only 4 doctors, 3 nurses and 1 pharmacist. Due to the volume of patients, Nurse Rey, was asked to participate in per forming circumcision with the rest of the doctors. Nurse Rey can be 1iable of committing
- A. assault
- B. tort
- C. invasion of privacy
- D. malpractice
Correct Answer: D
Rationale: Nurse Rey can be liable of committing malpractice by performing circumcisions without the proper training, qualifications, and legal authority to do so. Malpractice refers to negligence or failure to provide a standard level of care that results in harm to a patient. In this case, Nurse Rey participating in performing circumcisions may not have the necessary skills and expertise compared to the doctors who are trained to perform such procedures. This can lead to potential harm or complications for the patients, making it a case of malpractice.
The last fire in the hospital was due to a malfunctioning equipment. The Fire extinguisher was nowhere to be found. What should have been practiced?
- A. A dedicated fire extinguisher must be in every strategic Place
- B. Place one fire extinguisher between two units.
- C. A fire extinguisher can be replaced with fire sensors.
- D. Borrowing fire extinguishers may be tolerated if on the same floor
Correct Answer: A
Rationale: The correct practice in this situation would be to have a dedicated fire extinguisher in every strategic location throughout the hospital. Having fire extinguishers readily available in key areas ensures that they can be accessed quickly in case of a fire emergency. Placing one fire extinguisher between two units may not be sufficient as it may not be easily accessible in the event of a fire. Fire extinguishers should not be replaced with fire sensors as these serve different functions. Additionally, borrowing fire extinguishers may not be a safe or reliable practice, as they should be properly maintained and placed according to safety standards. Therefore, having dedicated fire extinguishers in every strategic location is the best practice to ensure the safety and well-being of individuals in the hospital.