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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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The nurse is monitoring a patient with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? (Select all that apply.)
- A. Cool, clammy skin
- B. Altered sensorium
- C. Pulse oximeter reading of 95%
- D. Respiratory rate of less than 12 breaths per minute
Correct Answer: B
Rationale: The signs of magnesium toxicity that the nurse should monitor for in a patient with severe preeclampsia on IV magnesium sulfate include an altered sensorium (confusion, lethargy, slurred speech) and a respiratory rate of less than 12 breaths per minute. Altered sensorium is a common symptom of magnesium toxicity, reflecting the drug's central nervous system depressant effects. A decreased respiratory rate can indicate respiratory depression, a potentially serious complication of magnesium toxicity. Monitoring for these signs is crucial to promptly identifying and managing magnesium toxicity in patients on magnesium sulfate therapy. Signs such as cool, clammy skin and a pulse oximeter reading of 95% would not be indicative of magnesium toxicity.
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 male patient with a metastatic brain tumor is having a generalized seizure and begins vomiting. What should the nurse do first?
- A. Perform oral suctioning.
- B. Page the physician.
- C. Insert a tongue depressor into the patients mouth.
- D. Turn the patient on his side.
Correct Answer: D
Rationale: When a patient is experiencing a seizure and begins vomiting, the priority action for the nurse is to turn the patient onto their side. This position helps to prevent aspiration, which can occur when the patient inhales vomit into their lungs. Turning the patient on their side allows for the vomit to drain out of the mouth, reducing the risk of aspiration and maintaining a clear airway. Performing oral suctioning would be necessary after turning the patient on their side, but it is not the initial priority in this situation. Paging the physician and inserting a tongue depressor are not appropriate actions during a seizure and vomiting episode.
A nurse is asked how many kcal per gram fats provided. How should the nurse answer?
- A. 3
- B. 4
- C. 6
- D. 9
Correct Answer: D
Rationale: Fats, also known as lipids, are the most calorie-dense nutrient, providing 9 kcal per gram. This high calorie content is due to the structure of fats, which contain more carbon-hydrogen bonds, making them more energy-dense compared to carbohydrates and proteins. Carbohydrates and proteins, on the other hand, provide 4 kcal per gram each. This makes fats an important source of energy in the diet, but they should be consumed in moderation to maintain a healthy balance of nutrients.
A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if the patient experiences what?
- A. Slight morning discharge from the eye
- B. Any appearance of redness of the eye
- C. A scratchy feeling in the eye
- D. A new floater in vision
Correct Answer: B
Rationale: Redness of the eye after cataract surgery can be a sign of infection or inflammation, which are serious complications that require immediate medical attention. Redness may be accompanied by pain, swelling, or discharge, and if left untreated, it can lead to complications that may affect the surgical outcome and the patient's vision. Therefore, it is crucial for the patient to contact the office immediately if they notice any redness in their eye following cataract surgery.