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A nurse is teaching a patient about the urinarysystem. In which order will the nurse present the structures, following the flow of urine?
- A. Kidney, urethra, bladder, ureters
- B. Kidney, ureters, bladder, urethra
- C. Bladder, kidney, ureters, urethra
- D. Bladder, kidney, urethra, ureters
Correct Answer: B
Rationale: The correct order is B: Kidney, ureters, bladder, urethra.
1. Kidneys filter blood and produce urine.
2. Ureters transport urine from kidneys to bladder.
3. Bladder stores urine until expelled.
4. Urethra carries urine from bladder out of the body.
Other choices are incorrect because they do not follow the anatomical flow of urine through the urinary system.
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Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately?
- A. The malleus can be visualized during otoscopic examination.
- B. The tympanic membrane is pearly gray.
- C. Tenderness is reported by the patient when the mastoid area is palpated.
- D. Clear, watery fluid is draining from the patients ear.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Clear, watery fluid draining from the ear post-accident indicates a possible cerebrospinal fluid (CSF) leak, a serious condition requiring immediate medical attention to prevent complications such as meningitis.
2. CSF leak can result from a basilar skull fracture, common in head injuries like motorcycle accidents.
3. Prompt reporting of this finding by the nurse is crucial for timely intervention and prevention of potential life-threatening complications.
Summary:
A: Visualizing the malleus during otoscopic examination is normal and not an immediate concern in this scenario.
B: A pearly gray tympanic membrane is a normal finding and does not indicate a serious issue post-accident.
C: Tenderness in the mastoid area may suggest injury but is not as urgent as clear, watery fluid drainage indicative of a CSF leak.
A patient has just been told that her illness is terminal. The patient tearfully states, I cant believe I am going to die. Why me? What is your best response?
- A. I know how you are feeling.
- B. You have lived a long life.
- C. This must be very difficult for you.
- D. Life can be so unfair.
Correct Answer: C
Rationale: The correct answer is C: "This must be very difficult for you." This response acknowledges the patient's emotional state and shows empathy without making assumptions or dismissing their feelings. It validates the patient's emotions and opens up the opportunity for further discussion or support.
Rationale:
1. A: "I know how you are feeling" assumes the tutor knows the exact emotions of the patient, which can come off as insincere or dismissive.
2. B: "You have lived a long life" does not address the patient's emotional distress or provide comfort in the face of a terminal illness.
3. D: "Life can be so unfair" does not directly address the patient's feelings and may come off as generic or cliché.
A nurse is reviewing results from a urine specimen.What will the nurse expect to see in a patient with a urinary tract infection?
- A. Casts
- B. Protein
- C. Crystals
- D. Bacteria
Correct Answer: D
Rationale: The correct answer is D: Bacteria. In a patient with a urinary tract infection (UTI), bacteria are typically present in the urine due to the infection of the urinary system. Bacteria may be detected through urine culture or microscopic examination.
A: Casts are not typically associated with UTIs but can indicate kidney disease.
B: Protein in the urine can indicate kidney damage or other issues, not specific to UTIs.
C: Crystals in the urine can be normal or indicate specific conditions, but they are not specific to UTIs.
In summary, the presence of bacteria in the urine is a key indicator of a UTI, while the other choices are more indicative of different conditions or factors.
A high-risk labor patient progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via cesarean birth. Which finding in the immediate postoperative period indicates that the patient is at risk of developing HELLP syndrome?
- A. Platelet count of 50,000/mcL
- B. Liver enzyme levels within normal range
- C. Negative for edema
- D. No evidence of nausea or vomiting
Correct Answer: A
Rationale: The correct answer is A: Platelet count of 50,000/mcL. HELLP syndrome is a severe form of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelet count. In this scenario, a platelet count of 50,000/mcL indicates thrombocytopenia, which is a key component of HELLP syndrome. Low platelet count can lead to bleeding complications and is a critical indicator of the syndrome.
Choices B, C, and D are incorrect.
B: Liver enzyme levels within normal range do not necessarily indicate the presence of HELLP syndrome, as elevated liver enzymes are a hallmark feature of the syndrome.
C: Being negative for edema is not a reliable indicator of HELLP syndrome, as edema is a common finding in preeclampsia but not specific to HELLP syndrome.
D: No evidence of nausea or vomiting is not a specific sign of HELLP syndrome, as these
A nurse is checking orders. Which order shouldthe nurse question?
- A. A normal saline enema to be repeated every 4 hours until stool is produced
- B. A hypertonic solution enema for a patient with fluid volume excess
- C. A Kayexalate enema for a patient with severe hypokalemia
- D. An oil retention enema for a patient with constipation
Correct Answer: B
Rationale: The correct answer is B because giving a hypertonic solution enema to a patient with fluid volume excess can worsen the condition by drawing more fluid into the colon. This can lead to further fluid volume overload and electrolyte imbalances. The other choices are incorrect because:
A: Normal saline enema is appropriate for constipation.
C: Kayexalate enema is used to treat hyperkalemia, not hypokalemia.
D: Oil retention enema is indicated for constipation to soften stool.