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A nurse is providing care to a group of patients.Which patient will the nurse seefirst?
- A. A child about to receive a normal saline enema
- B. A teenager about to receive loperamide for diarrhea
- C. An older patient with glaucoma about to receive an enema
- D. A middle-aged patient with myocardial infarction about to receive docusate sodium
Correct Answer: C
Rationale: The correct answer is C because an older patient with glaucoma is at risk for increased intraocular pressure when receiving an enema. This situation requires immediate attention to prevent potential complications like vision loss. The other choices do not pose immediate risks that require urgent intervention. A and B can wait for a brief period, while D is not time-sensitive in the context of a myocardial infarction. The priority is always given to the patient with the highest risk of harm if the intervention is delayed.
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The nurses plan of care for a patient with stage 3 HIV addresses the diagnosis of Risk for Impaired Skin Integrity Related to Candidiasis. What nursing intervention best addresses this risk?
- A. Providing thorough oral care before and after meals
- B. Administering prophylactic antibiotics
- C. Promoting nutrition and adequate fluid intake
- D. Applying skin emollients as needed
Correct Answer: A
Rationale: The correct answer is A: Providing thorough oral care before and after meals. This addresses the risk for impaired skin integrity related to Candidiasis in patients with stage 3 HIV by preventing oral Candidiasis, a common fungal infection. Poor oral hygiene can lead to Candidiasis, which can spread to the skin. Thorough oral care reduces the risk of oral Candidiasis, thereby preventing skin integrity issues. Administering prophylactic antibiotics (B) is not indicated for preventing Candidiasis. Promoting nutrition and fluid intake (C) is important for overall health but does not directly address the risk of impaired skin integrity. Applying skin emollients (D) may help with skin dryness but does not directly address the underlying cause of Candidiasis.
A placenta previa when the placental edge just reaches the internal os is called
- A. total.
- B. partial.
- C. low-lying.
- D. marginal.
Correct Answer: D
Rationale: The correct answer is D, marginal. Placenta previa is classified based on the proximity of the placental edge to the internal os. In a marginal placenta previa, the placental edge just reaches the internal os. This is a crucial distinction as it poses a higher risk for bleeding during labor. Total placenta previa covers the entire internal os, partial placenta previa partially covers the internal os, and low-lying placenta is when the placenta is close to but not covering the internal os. Therefore, D is correct as it accurately describes the specific position of the placenta edge in relation to the internal os in cases of marginal placenta previa.
A patient has returned to the floor from the PACU after undergoing a suprapubic prostatectomy. The nurse notes significant urine leakage around the suprapubic tube. What is the nurses most appropriate action?
- A. Cleanse the skin surrounding the suprapubic tube.
- B. Inform the urologist of this finding.
- C. Remove the suprapubic tube and apply a wet-to-dry dressing.
- D. Administer antispasmodic drugs as ordered.
Correct Answer: B
Rationale: The correct answer is B: Inform the urologist of this finding. In this scenario, significant urine leakage around the suprapubic tube indicates a potential issue with the tube placement or functioning. It is crucial to involve the urologist, who is the specialist managing the patient's urological interventions, to assess and address the cause of the leakage promptly. This action ensures timely and appropriate intervention to prevent complications such as infection or further damage.
Choice A is incorrect because simply cleansing the skin does not address the underlying issue of urine leakage. Choice C is incorrect and potentially harmful as removing the suprapubic tube without professional assessment can lead to serious complications. Choice D is incorrect as administering antispasmodic drugs may not be the appropriate action without further evaluation by the urologist.
What should the nurse recognize as evidence that the patient is recovering from preeclampsia?
- A. 1+ protein in urine
- B. 2+ pitting edema in lower extremities
- C. Urine output >100 mL/hour
- D. Deep tendon reflexes +2
Correct Answer: C
Rationale: Step 1: Increased urine output indicates improved kidney function, a key indicator of recovery from preeclampsia.
Step 2: Adequate urine output helps regulate blood pressure and reduce swelling.
Step 3: Consistent urine output >100 mL/hour signifies the kidneys are functioning properly.
Step 4: Therefore, C is the correct answer as it directly reflects recovery progress from preeclampsia.
Summary: A, B, and D are incorrect as they do not directly correlate with kidney function or recovery from preeclampsia.
A nurse is addressing the incidence and prevalence of HIV infection among older adults. What principle should guide the nurses choice of educational interventions?
- A. Many older adults do not see themselves as being at risk for HIV infection.
- B. Many older adults are not aware of the difference between HIV and AIDS.
- C. Older adults tend to have more sex partners than younger adults.
- D. Older adults have the highest incidence of intravenous drug use.
Correct Answer: A
Rationale: The correct answer is A because it addresses the key issue of perception of risk among older adults. Many older adults may not perceive themselves as being at risk for HIV infection due to misconceptions or lack of awareness. This principle guides the nurse to tailor educational interventions to address this specific barrier. Choices B, C, and D are incorrect as they do not directly address the perception of risk among older adults. Older adults' awareness of HIV/AIDS, number of sex partners, or incidence of intravenous drug use are not the primary factors influencing their perception of HIV risk.