Nokea
A nurse is providing discharge teaching for apatient who is going home with a guaiac test. Which statement by the patient indicates the need for further education?
- A. “If I get a blue color that means the test is negative.”
- B. “I should not get any urine on the stool I am testing.”
- C. “If I eat red meat before my test, it could give me false results.”
- D. “I should check with my doctor to stop taking aspirin before the test.”
Correct Answer: A
Rationale: The statement "If I get a blue color that means the test is negative" given by the patient indicates the need for further education. This is incorrect information because a blue color in the guaiac test indicates a positive result, which means the presence of fecal occult blood. The patient should be taught that a positive result indicates the need for further evaluation and follow-up with their healthcare provider. Proper understanding of the test results is vital to ensure accurate interpretation and appropriate management. Further clarification and education are necessary to correct this misconception and guide the patient towards understanding the significance of a positive result.
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A nurse is evaluating a nursing assistive personnel’s(NAP) care for a patient with an indwelling catheter. Which action by the NAP will cause the nurse to intervene?
- A. Emptying the drainage bag when half full
- B. Kinking the catheter tubing to obtain a urine specimen
- C. Placing the drainage bag on the side rail of the patient’s bed
- D. Securing the catheter tubing to the patient’s thigh
Correct Answer: C
Rationale: Placing the drainage bag on the side rail of the bed could allow the bag to be raised above the level of the bladder and urine to flow back into the bladder. The urine in the drainage bag is a medium for bacteria; allowing it to reenter the bladder can cause infection. A key intervention to prevent catheter-associated urinary tract infections is prevention of urine back flow from the tubing and bag into the bladder. All the other actions are correct procedures and do not require immediate follow-up. The drainage bag should be emptied when it is half full to prevent tension and pulling on the catheter, which could result in trauma to the urethra and increase the risk for urinary tract infections. Urine specimens are traditionally obtained by temporarily kinking the tubing, while securing the catheter tubing to the patient’s thigh prevents catheter dislodgment and tissue injury.
The nurse is caring for a patient who has undergone a mastoidectomy. In an effort to prevent postoperative infection, what intervention should the nurse implement?
- A. Teach the patient about the risks of ototoxic medications.
- B. Instruct the patient to protect the ear from water for several weeks.
- C. Teach the patient to remove cerumen safely at least once per week.
- D. Instruct the patient to protect the ear from temperature extremes until healing is complete.
Correct Answer: B
Rationale: After a mastoidectomy, the ear should be protected from water for several weeks. This is because exposing the area to water can increase the risk of infection. Keeping the ear dry allows the surgical site to heal properly and reduces the likelihood of postoperative complications such as infection. Therefore, instructing the patient to protect the ear from water is an important intervention to prevent postoperative infection following a mastoidectomy.
A patient who has AIDS is being treated in the hospital and admits to having periods of extreme anxiety. What would be the most appropriate nursing intervention?
- A. Teach the patient guided imagery.
- B. Give the patient more control of her antiretroviral regimen.
- C. Increase the patients activity level.
- D. Collaborate with the patients physician to obtain an order for hydromorphone.
Correct Answer: A
Rationale: The most appropriate nursing intervention for a patient with AIDS experiencing extreme anxiety is to teach the patient guided imagery. Guided imagery is a relaxation technique that can help the patient reduce anxiety levels, promote a sense of calm, and improve overall well-being. By teaching the patient how to use guided imagery, the nurse empowers the patient to manage her anxiety in a non-pharmacological way. This intervention promotes self-care and allows the patient to have a tool to use independently beyond the hospital setting. Giving the patient more control of her antiretroviral regimen may be beneficial for adherence but does not directly address the anxiety symptoms. Increasing the patient's activity level may be helpful for overall well-being but may not specifically target the extreme anxiety. Collaborating with the patient's physician to obtain an order for hydromorphone, a potent opioid medication, is not appropriate unless it is indicated for severe pain management, not anxiety.
The nurse educator is discussing neoplasms with a group of recent graduates. The educator explains that he effects of neoplasms are caused by the compression and infiltration of normal tissue. The physiologic changes that result can cause what pathophysiologic events? Select all that apply.
- A. Intracranial hemorrhage
- B. Infection of cerebrospinal fluid
- C. Increased ICP
- D. Focal neurologic signs E) Altered pituitary function
Correct Answer: A
Rationale: Neoplasms can cause pathophysiologic events such as intracranial hemorrhage and increased intracranial pressure (ICP) due to expansion of the mass within the confined space of the skull. Intracranial hemorrhage can occur as the neoplasm damages blood vessels in the brain or causes them to become more fragile. Increased ICP can result from the growing mass causing compression of surrounding structures and obstructing the flow of cerebrospinal fluid, leading to symptoms such as headaches, nausea, vomiting, and changes in mental status.
A patient who is scheduled for a skin test informs the nurse that he has been taking corticesteroids to help control his allergy symptoms. What nursing intervention should the nurse implement?
- A. The patient should take his corticosteroids regularly prior to testing.
- B. The patient should only be tested for grass, mold, and dust initially.
- C. The nurse should have an emergency cart available in case of anaphylaxis during the test.
- D. The patients test should be cancelled until he is off his corticosteroids.
Correct Answer: A
Rationale: The patient should continue taking his corticosteroids regularly prior to testing. Corticosteroids can suppress the body's immune response and affect the results of skin tests by potentially causing a false-negative result. Instructing the patient to maintain his regular corticosteroid regimen will help ensure accurate testing results. It is essential to consult with the healthcare provider to determine the appropriate timing for testing in relation to corticosteroid use.